Analysis of urgent inpatient neurologic consultations in a large tertiary hospital center: Follow‐up on the effect of standardized training of residents

Abstract Background Clinical neurology is difficult for young residents. To familiarize with neurological emergencies as soon as possible for young doctors, the urgent inpatient neurologic consultations were analyzed. Methods A retrospective study was conducted on the urgent inpatient neurologic consultations in a large tertiary hospital for 4 consecutive years. Results A total of 1437 cases were included, and the annual consultation cases gradually decreased from 573 to 257, involving 29 clinical departments. The disorders of urgent inpatient neurologic consultations were divided into three categories: neurological disorders (77.8%), non‐neurological disorders (10.4%), and undiagnosed disorders (11.8%), common causes in consultation were disturbance of consciousness (36.0%), convulsions/stiffness (13.6%), limb weakness (8%), and mental disorder (5.6%). Common neurological disorders included acute cerebrovascular disease (33.6%), epilepsy/status epilepticus (15.8%), and metabolic or infectious toxic encephalopathy (14.9%). Conclusion Urgent inpatient neurologic consultations involve multidisciplinary critical diseases, mainly neurological diseases. The standardized training of residents may help to rapidly improve the comprehensive diagnosis and treatment ability of young residents and is suitable for use in hospitals at all levels.

residents in different departments. Therefore, the urgent inpatient neurologic consultations are very common in tertiary hospital centers.
Acute and critical neurological disorders are characterized by rapid onset and rapid progression. If the disease is not properly diagnosed and treated promptly, there will be more complications and higher mortality. Rapid and accurate diagnosis and treatment are critical for improving outcomes in acute neurological disorders (Greene, 2018).
The main purpose of the urgent inpatient neurologic consultations is to help other departments manage life-threatening symptoms as quickly as possible. With rapid response, cure rates and quality of life are improved, whereas morbidity and mortality are reduced. After their training period in Spain, neurologists in training were informed about EEG in 49% of education units. It has been reported that the demand for neurology specialists exceeds the supply (Busetto et al., 2022;Rodríguez-Antigüedad et al., 2011). However, there have been few previous studies that have looked into urgent inpatient neurologic consultations. The National Standardized Training of Residents was officially implemented in 2014. The effect of Standardized Resident Training is unknown. Thus, the purpose of this study is to look into urgent inpatient neurologic consultations in order to help young doimpactctors become familiar with neurological emergencies and to understand the effect of Standardized Training of Residents.

Statistical analysis
Microsoft Excel was used for data collection and to create tables.
Countable data values were presented as the mean ± SD. Data processing was done using SPSS version 23.0.

General information
There were 1618 urgent inpatient neurologic consultations within 4 years: 573 in 2014, 406 in 2015, 382 in 2016, and 257 in 2017, which decreased year after year. Of these, 136 had at least two consultations, these were each considered 1 case in the data, and 1437 were eventually included in the study, of whom 54.6% were male and 45.4% were female, with a mean age of 60.3 years (range: 9-103).

Consulting departments involved
Urgent inpatient neurologic consultations involved 29 clinical departments ( Figure 1), 990 cases in the general ward and 447 cases in the intensive care unit (ICU). Overall, 68.3% of cases were from internal medicine and surgery, which was similar with the observations previously in Jordan (Lahlouh et al., 2020). Among the internal medicine departments, the departments that applied for urgent consultations were the emergency department (12%), respiratory department (11.9%), cardiology department (11%), hematology department (7%), and nephrology department (6%). The departments that requested the most urgent consultations among the surgical departments were thoracic surgery (13%), orthopedics (12%), vascular surgery (11%), hepatobiliary surgery (10%), and ICU surgery (10%).

Illness and counseling purposes
Common purposes for urgent inpatient neurologic consultations were the undiagnosed diseases (80%), assistance in treatment (14%), and F I G U R E 1 Department distribution of urgent inpatient neurologic consultations.
controversial cases (6%) ( Table 1). The patients' requests more frequently for urgent inpatient neurologic consultations in the older patients with mean age 74.5 years in the study. Non-neurological diseases accounted for 10.4% of the total urgent neurologic consultations. Some of the cases were used to rule out potential problems during the differential diagnosis process.
However, some of them were not. It implies that they lack both the necessary standardized training and basic medical knowledge. Unknown diseases accounted for 11.8%. There were many reasons for these, including highly complicated diseases and refusal of further testing by the patient (Figure 2).

DISCUSSION
The study obtained two main findings: First, urgent inpatient neuro-  which is operated by several full-time experts. The positive results of the detection of acid-fast bacilli are more than 80%, and abnormal cells may also be found in cerebral spinal fluid. They could also detect more than 10 antibodies associated with autoimmune encephalitis with high specificity and sensitivity. As a result, hospital neurologists can better manage the diagnosis and treatment of encephalitis as soon as possible.

Reasons for consultation Number of cases
Departments that frequently request urgent neurologic consultations include the ICU, respiratory medicine, cardiovascular medicine, hematology, and nephrology. In previous reports, it has been estimated that approximately 10% of patients with medical conditions will have some neurological manifestations (Coban et al., 2016;Do & Siegler, 2018;Ropper, 2016 (Roland et al., 2018), and the treatment was mainly to maintain the stability of the internal environment to treat the primary disease. Pain was also a common reason for counseling in previous studies (Morrish, 2015;Sakashita et al., 2018). There are cases in which a neurosurgeon should be consulted rather than a neurologist, such as brain contusions and lacerations, basilar fractures, diffuse axonal injury, intracranial tumors, hydrocephalus, and subdural hematoma.
Therefore, it is necessary for clinicians to have a basic knowledge of neurology and neurosurgery.
In addition, some consultations should be regularly rather than urgent. For example, a patient with Parkinson's disease requested an urgent inpatient neurologic consultation for an intravenous ganglioside infusion. Preoperative evaluation and secondary prevention of cerebrovascular disease are performed surgically sometime, and it is better to request regular neurologic inpatient consultations rather than urgent inpatient neurologic consultations.

CONCLUSIONS
Non-neurological medical staff should strengthen their understanding of common acute and critical illnesses, and neurologists should provide more on-the-job training related to neurological diseases for young doctors in the hospital to reduce blind spots and inappropriate clinical work. For invitation to urgent inpatient neurologic consultation, the Standardized Training of Residents is helpful to rapidly improve the comprehensive diagnosis and treatment ability of young residents and is suitable for application in hospitals at all levels.

ACKNOWLEDGMENTS
The authors thank Yi Yang and Lijuan Wang for assistance in data analysis. Open access funding was provided by the First Affiliated Hospital of Chongqing Medical University. No funding was received for conducting this study.

CONFLICT OF INTEREST STATEMENT
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

DATA AVAILABILITY STATEMENT
Data would be available by contacting corresponding author and after excluding the personal information of patients.

INFORMED CONSENT
Written consent was waived, as this retrospective study does not influence the health care of included individuals. All patients' data were anonymized.