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.