November 22, 2002

New service targets faster, more efficient emergency general surgery consults at VUMC

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Dr. Rick Belcher, left, has an emergency general surgery consult with Dr. Jose Diaz and Dr. Willie Melvin in the Emergency Department. (photo by Dana Johnson)

New service targets faster, more efficient emergency general surgery consults at VUMC

Since starting the emergency general surgery consult service, Dr. Jose Diaz, assistant professor of Surgery in Trauma and Surgical Critical Care Medicine, doesn’t have more time on his hands, but he knows more often how he’s going to spend it.

Prior to the new service, which went into effect Aug. 1 and has been slightly tweaked now and then since, Diaz and other surgeons covering the consults were routinely paged out of elective clinics or scheduled surgeries, or called out of labs or research centers.

“If a true emergency came in, it basically disrupted your entire day,” he said. “If you were a patient coming in for an elective case and your surgeon was on call that day, you were suddenly stuck behind somebody else. For the business that we’re in of trying to improve the best elective surgical services to the community, that negatively affected our outlook.”

Under Diaz’ new system, a group of 18 surgeons from various services, including trauma, surgical oncology and general surgery, all of whom expressed a special interest in emergency general surgery, rotate being on call from 7 a.m. until 5 p.m., and have dedicated time during the day to answer these consults, whether they be at the bedside in the emergency department or over the phone with a referring physician from the Wilson Medical Group, Hillsboro Medical Group or another Nashville-area practice, or from as far away as Kentucky or Alabama. They divide weekends and a 5 p.m. to 7 a.m. shift to provide 24/7 coverage.

“We hope to improve the professional relations with other departments, to improve the relations with outside community physicians and to smooth the transfer process for surgical patients,” said Dr. C. Wright Pinson, H. William Scott Professor and chairman of the Department of Surgery and Vanderbilt University Hospital chief of staff. “While our goal is to provide very quick response for urgent consultations and/or operations, the existence of this service does not preclude any referring doctor from contacting, through other usual pathways, preferred surgical consultants not on call for this service.”

The new consult service follows models at other busy hospital systems, like those at the Mayo Clinic-affiliated hospitals and at the University of Michigan, Diaz says. “They also are major referral centers for complex general surgical problems for surrounding rural hospitals that don’t have the expertise” for complicated emergency general surgery.

The game plan is this: the requesting physician calls for the consult (on campus it’s the Once Center number, 343-8040, and from off-campus calls go through the Transfer Center number, 343-0976); the message center sends a text page to the attending on-call physician and, simultaneously, to a third-year surgery resident on the same coverage. The page specifies “emergent consult,” it lists an initial diagnosis and gives the location (“emergency department”) or a phone number. The attending and the resident rapidly respond together, and a surgical decision is made.

The system adds structure to an increasingly busy service. The biggest advantage is having dedicated time for attendings to respond to consults, which also assures their patients’ days are not disrupted.

It’s early to measure success, especially since the system provides for the first time the collection of emergency general surgery data. In August, the service had 115 in-house consults and 50 patient transfers. Included in the data are the times when an attending and resident are paged and when they provide the consult, which adds an element of accountability.

The service also affords the opportunity to improve business relations with the important network of physicians outside Nashville. Vanderbilt has already demonstrated an aplomb transferring patients, Diaz said, utilizing LifeFlight (including the new third helicopter based in Clarksville) as the conduit between community hospitals and Vanderbilt’s critical care units. Buffing up emergency general surgery consults stands to increase LifeFlight volume and, consequently, the number of patients utilizing a high level of critical care management and additional surgical procedures.

Prior to the service, Diaz said, there was no method in place to count the number of consults coming in and how many became admissions, or how many admissions resulted in operations. Now, that’s all being tracked, and response times are being plotted so improvements can be made.

But its success begins and ends with patient care. “The service is important to the community in and of itself,” Diaz said. “As we develop the service and identify the patients we’re likely to get, we can develop patient management guidelines. And for those who utilize the intensive care unit we can dovetail some of the ICU patient practice guidelines as well.”