4. Discussion
For most physicians, neurology is a complicated subject that encompasses
many critical diseases. It also presents a difficult area with many
blind spots in medical diagnosis and treatment. Therefore, urgent
consultation in neurology departments is very common in tertiary
hospital centers. This study obtained two main findings. First,
neurological diseases accounted for 77.8% of the total cases of urgent
consultation diseases, 57.5% of which were in line with urgent
consultation criteria. Second, the most common reasons for urgent
consultation were disturbances of consciousness, tics/stiffness, limb
weakness, and mental disorders. Common neurological disorders were acute
cerebrovascular disease (33.6%), epilepsy/status epilepticus, and
metabolic or infectious toxic encephalopathy.
Among the 1437 cases of urgent consultation, the actual number of cases
decreased year by year, from 573 in 2014 to 257 in 2017. This may be
attributable to improvements in the clinical skills of non-neurologists
at the hospital as well as effective management by the hospital’s
medical services section. The data shown show that most urgent
consultations have been adjusted reasonably and appropriately according
to predefined criteria. There are many reasons for this. First, the
hospital’s management has placed greater emphasis on the importance of
basic medical knowledge and skills. A great deal of training for
continuing medical education has been conducted. Second, there is a
standardized clinical pathway for physicians to reference regarding
several neurological diseases. However, non neurologists should enhance
their understanding of nervous system diseases, so as to make better
judgment on the conditions related to emergency neurology consultation.
Further, medical management bodies should adopt appropriate measures to
enhance the effectiveness of urgent consultation.
In urgent consultation, acute cerebrovascular diseases accounted for
33.6% of cases, including cerebral infarction, cerebral hemorrhage, and
transient ischemic attack; this is similar to previous findings [9].
In the study hospital, the average age of urgent consultation patients
was 60.3 years old; this could be related to the increased incidence of
stroke with age [6]. Most consultations were in line with the
guidelines for urgent consultation because the hospital’s physicians
were more skilled now at diagnosing and treating acute cerebrovascular
diseases. There were 177 cases of epilepsy/epileptic-persistent states,
which differs from the common urgent consultation diseases reported in
domestic emergency consultation studies. The main reason could be that
the study hospital has an epileptic center that is, in fact, one of
China’s well-known epilepsy centers. The center has several epilepsy
experts and a large number of regular follow-up patients who come from
neighboring areas with poor treatment managed by non-specialists. Cases
of metabolic or infective toxic encephalopathy and encephalitis
comprised the third-largest group for urgent neurological consultation.
Many patients with encephalopathy and encephalitis are treated for
longer periods of time. The study hospital houses the XX Key Laboratory
of Neurology, which is operated by full-time specialists who can detect
acid-fast bacillus with more than 80% positive results and abscissa
cells. They can also detect more than 10 antibodies related to
autoimmune encephalitis, which are highly specific and sensitive. Thus,
the neurological physicians at the hospital can better manage the
diagnosis and treatment of encephalitis.
Departments that frequently applied for urgent neurological consultation
included the intensive care unit (ICU), respiratory medicine,
cardiovascular medicine, hematology, and nephrology. At present, it is
estimated that about 10% of patients present some neurological
manifestations in the previous reports[10–13]. It has been reported
that neurological consultation in the ICU is often urgent consultation,
which also suggests that patients have more severe diseases to be
managed. At the same time, some ICU doctors lack relevant knowledge
about critical neurological illnesses. It is advised that internal
medicine residents should be trained in neurological areas for at least
6 months of the 3-year standardized resident training in China. In
addition, ICU physicians at the study hospital should attend more
lectures on emergency neurology. Most patients in cardiovascular and
nephrology department have risk factors of angiosclerosis, often
accompanied by cerebrovascular disease. Patients with renal failure are
consulted by neurology because of their impaired consciousness or
convulsions during dialysis, which are due to internal environment
dysfunction, renal encephalopathy, and dialysis encephalopathy.
The common reasons for applications for consultation in the respiratory
medicine department included convulsions and disturbances of
consciousness; the etiology was mostly pulmonary encephalopathy or
ischemic and hypoxic encephalopathy. First, it is very important for
them to control the primary disease. If patients with lung tuberculosis
present with headaches, disturbances of consciousness, convulsions, or
hyponatremia, tuberculosis meningitis should be considered. Then,
patients should be prescribed a routine with lumbar puncture for
cerebrospinal fluid analysis, dynamic electroencephalogram, and MRI.
Once a patient is diagnosed with tuberculosis meningitis,
antituberculosis drugs should be prescribed as soon as possible.
The main reason for applying for urgent consultation in the surgical
department was impaired consciousness. Uncontrollable postoperative
epilepsy is among the special cases for the neurosurgery department.
However, the preoperative evaluation and secondary prevention of
cerebrovascular disease often take place in the surgical department,
which should be consulted regularly rather than through urgent
consultation.
Accurate case histories and neurologic examinations may help physicians
differentiate neurological diseases. There were 150 cases of
nonneurological diseases, including restlessness, mental disorder,
disturbances of consciousness, and headaches; these were considered to
be related to internal environmental disorders, primary diseases,
hypertension, anxiety, and vagal reflex syncope. Some physicians confuse
aphasia with unclear utterances in mental disturbance. Therefore, to
reduce unnecessary urgent neurological consultations, physicians should
rule out the above diseases before applying for an urgent neurological
consultation. Acute encephalopathy is often secondary to infection after
cardiopulmonary resuscitation or metabolic disease. To control the
primary causes is the main measure. Before applying for consultation, it
is suggested that physicians perform blood gas analysis,
electroencephalogram, blood glucose and electrolyte analysis, and skull
CT, and take a detailed history of drug use, including sedatives and
antidepressants. In the case of urgent consciousness disorders and
cognitive impairment after surgery, drugs with adverse effects should be
considered first. Thus, physicians should be familiar with the adverse
effects of anesthetic drugs. For tetanus/convulsion, as one common
reason for urgent consultation, physicians should be familiar with the
possible causes of convulsion, including diseases related to respiratory
medicine, cardiology, and other types of internal medicine. Only some of
these cases of convulsion are diagnosed as epilepsy, which should apply
for neurological consultation.
Nonneurological diseases accounted for 10.4% of cases. Internal
medicine and surgical departments accounted for half, including
respiratory, cardiology, orthopedics, obstetrics and gynecology, and
digestive departments. Nonneurologic diseases presenting with
irritability and delirium but with no focal nervous system signs can be
regarded as differential criteria for neurological diseases. Most
consultation patients with nonneurologic diseases had no new structural
damage in their central nervous systems [14], and treatment was
mainly intended to maintain the stability of the internal environment
for the treatment of primary diseases. Pain has also been a common cause
of consultation in previous studies [15]. Some cases should involve
consultation with a neurosurgical physician rather than a neurological
physician. These include cerebral contusion and laceration, skull base
fracture, diffuse axonal injury, intracranial tumor, hydrocephalus, and
subdural hematoma. Physicians should therefore improve their
neurosurgical knowledge.
In addition, some consultations should be ordinary rather than urgent.
For example, one patient with Parkinson’s disease applied for urgent
consultation because of treatment with the intravenous infusion of
ganglioside. There were 169 cases that could not be diagnosed because of
severe disease, failure to complete relevant examinations, or poor
recording by physicians.
To conclude, medical staff in non-neurologic departments should
strengthen their knowledge of common urgent and critical diseases, while
neurological physicians should provide more in-service training for
young physicians.