UC San Diego

Background:As a consequence of the modern EMR, the vast majority of consultant recommendations are provided through electronic notes as opposed to direct communication. While this promotes accessibility and transparency, a significant amount of nuanced decision-making can be lost in the note-writing and note-interpretation process. In turn, the lack of interaction between colleagues can create a sense of separation between consultants and the primary service, thereby creating opportunities for errors in patient care. VA San Diego is not immune to this phenomenon; the internal medicine service is the primary team for the majority of admitted patients and relies on prompt and clear consultant recommendations, and frequently encounters problems with delayed or unclear consults. In response to this, we implemented a strategy to improve communication between neurology consultants and the primary medical services.

Methods:Our intervention involved requiring neurology consultants to provide daily face-to-face recommendations to the primary medicine services, as opposed to relying solely on electronic notes in the EMR. This study was implemented over a six-month period between 9/2022 and 2/2023. Internal Medicine residents evaluated their interactions with neurology consultants before and after this six-month period using a pre- and post- survey. Residents were asked to rate their agreement with the following statements on a scale from 1-7.

Neurology consultants appropriately communicate management recommendations. You are able to understand the reasoning behind why a particular neurology recommendation was made. Your ability to manage neurological conditions improves after interacting with neurology consultants. You feel supported by the neurology team when taking care of complex neurological patients. A free-text space was also provided in the survey for residents to add additional recommendations on how the neurology team could improve the workflow of medicine teams.

Results: In this prospective study, a total of 45 responses were recorded; 24 prior to intervention and 21 post-intervention. There was a statistically significant improvement in mean scores for statement 1, 2, and 4 over the 6-month period. The mean score for statement 1 increased from 4.2 to 5.6 (p<0.05), statement 2 increased from 4.1 to 5.1 (p< 0.05), statement three increased from 4.7 to 5.4 (p=0.11), and statement four from 4.5 to 5.7 (p<0.05). In total, scores increased on average of 1.2 points after intervention.

Conclusions:Neurology consultants providing in-person management recommendations to the primary medicine services significantly improved quality metrics concerning their ability to manage neurological patients. Specifically, in-person recommendations improved overall communication and understanding of consultant recommendations, and suggest that in-person management recommendations may improve in-hospital patient care. Further studies will need to be done to determine the broader effect on patient care, burden on consultant load, and applicability to other specialties.