Appropriateness of Pediatric Surgical Consultations From the Emergency Department: A 2-Center Study

Introduction

Emergency departments provide uninterrupted services 24/7, where all types of emergency patients are treated. It is one of the most important hospital units. Approximately one-third of the emergency service visits were children [1]. An interdisciplinary approach is often required for diagnosis and treatment of these patients. Consultations constitute the majority of the workload of emergency services, which serve a large patient population.

The steadily increasing number of visits to pediatric emergency departments (PED) continues to pose a significant problem in terms of physician and staff workload. In addition to contributing to physician workload and burnout, studies have shown that an increasing number of visits is associated with increased mortality [2,3]. The increased workload directly affects the number of consultations. The rise in the number of consultations, in turn, prolongs the length of hospital stay in proportion to the time required to complete the consultation. Consultation rates are on average 20% to 40% for adult emergencies [4].

In centers such as university hospitals, where medical education is provided, the presence of interns and resident physicians, as well as the employment of newly graduated doctors in smaller centers, particularly in emergency departments, leads to significant inefficiencies in the consultation process. These inefficiencies result in increased workload, time, and financial burden on the hospital and staff and also lead to extended hospital stays, and unnecessary diagnostic tests and treatments for patients. Numerous studies have proposed solutions regarding this problem, such as the decision to request consultation, consulting with senior physicians, and expediting consultation responses [5,6].

Pediatric surgery (PS) training is more challenging than training in other specialties. Considering the number of pediatric surgeons and the duration of training worldwide, it has been observed that in many countries, the number of pediatric surgeons is insufficient, and due to various difficulties, its popularity among doctors is low. The number of pediatric surgeons per one million children varies between 0.51 and 29.3 across countries, being inversely proportional to the number of births and directly proportional to the gross domestic product (GDP) [7–9].

In Turkey, there are approximately 800 active pediatric surgeons, 550 of whom are registered with the National Association of PS, corresponding to 3.6 pediatric surgeons per 100 000 children. According to workload data, the optimal number of pediatric surgeons is 1 for every 100 000 children [8,10]. However, these figures do not reflect the number of pediatric surgeons serving as consultants; therefore, the number of active pediatric surgeons who carry the main workload is significantly lower than the percentages worldwide [11]. There are no published data regarding pediatric surgery consultations in the PED.

Although the shortage of pediatric surgeons may be expected to influence the quality of care and patient outcomes, our study did not aim to directly analyze these effects. Rather, the purpose of highlighting these figures was to provide context regarding the global and national workload burden on pediatric surgery departments. The present study was specifically designed to evaluate consultation patterns, appropriateness, and the consultation-related workload imposed on pediatric surgeons by the pediatric emergency department.

This study aimed to determine the true consultation indication rate by examining the epidemiology, consultation responses, and progression of patients for whom a consultation indication was made between the PED and PS. In addition, we obtained documented data on the consultation-based workload imposed by the PED in the PS department.

Material and Methods

STUDY DESIGN AND SETTING:

This study was designed retrospectively based on data from the departments of PS in 2 different cities. KTU is a university state and tertiary care children’s hospital located in Trabzon, which serves an immediate population of approximately 822 000 people. ODU is a university state hospital and tertiary care children’s hospital, located in Ordu, that serves an immediate population of approximately 775 000 people.

The medical records of patients aged 0 to 18 years who presented to the PED of KTU and ODU hospitals in 2023 and for whom a consultation with the Department of PS was requested. The dataset included patient age and sex, time of consultation, reasons for consultation requests, consultation responses, and information regarding hospitalization and/or surgical intervention (Figure 1).

Ethics approval for this study was obtained on 14/06/2024, with protocol number 2024/134, by the KTU Institutional Review Board.

Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of KTU Institutional Review Board (Approval No: 14.06.2024 with protocol number 2024/134).

DATA COLLECTION:

This study was conducted by reviewing the data of 1639 patients for whom who consultation was requested with a pediatric surgery department from a total of 52 660 patients who presented to the pediatric emergency departments of 2 university hospitals in 2023. Of these 1639 patients, 388 were from the ODU hospital and 1251 were from the KTU hospital. In retrospective file reviews, only emergency department consultations were included in the study; emergency consultation requests from other departments were not included. For standardization of the evaluation, consultations initiated by the PED but considered unrelated to pediatric surgery by the PS department were categorized under the heading “pediatric evaluation recommendation”, as the consultation responses predominantly included recommendations for pediatric evaluation or general pediatric treatment. Consultation responses were reviewed individually, and the cases in which no diagnosis was established from the pediatric surgery perspective and/or no treatment recommendation was provided were classified as the ‘pediatric evaluation recommendation’ group. To ensure standardization across both centers, patients in this group were those whose progress was monitored and who were re-evaluated by the pediatric emergency department or pediatrics clinic following completion of the pediatric surgery consultation. To assess the time-related aspects of the consultations, the consultation hours were classified as ‘daytime’ and ‘nighttime’ based on the shift changes between working and on-call hours and were included in the study accordingly.

STATISTICAL ANALYSIS:

Statistical analyses were performed using SPSS version 25.0. Descriptive analyses were performed using mean, standard deviation, median, and min-max values. Consultation justification rates were compared between groups using the chi-square/Fisher exact test. P values below 0.05 were evaluated as statistically significant results.

Results

In 2023, out of 52 660 pediatric patients, a PS consultation was requested for 1639 (3.1%). The average number of daily consultations was 4.4. The mean patient age was 6.6 years. Among them, 667 (40.6%) were female and 972 (59.4%) were male. When the timing of the consultation requests was evaluated, 537 (32.7%) occurred during working hours (daytime), while 1102 (67.2%) occurred outside of working hours during duty/on-call periods (nighttime).

Based on the responses to consultations and clinical progress, 312 (19%) patients underwent surgical intervention. A total of 326 (19.8%) patients were admitted to the ward for treatment or follow-up, without surgery. Additionally, 165 (10%) patients were discharged after consultation, with the outpatient treatment recommendations. Pediatric evaluation was recommended for 836 patients, accounting for 51% of all patients (Table 1, Figure 2).

The total hospitalization/consultation rate was 338/1639 (20.6%). Preliminary diagnoses were evaluated, and 710 (43.3%) patients reported having abdominal pain and/or had suspected appendicitis. Of the patients, 92 (12.9%) were hospitalized only and 145 (20.4%) underwent appendectomy. When evaluated on a hospital basis, 168 (43.2%) pediatric surgery consultations at the ODU and 542 (43.3%) at the KTU were referred for abdominal pain and/or suspected appendicitis, with similar proportions. Regarding surgical interventions, 40 (23.8%) patients underwent surgery at the ODU and 105 (19.3%) patients underwent surgery at the KTU.

Upon reviewing the records of the remaining 473 patients, a pediatric evaluation was recommended for 297 patients (41%). A total of 176 patients (59%) were diagnosed with constipation, treated on an outpatient basis, and discharged. The second most common reason for consultation was foreign body ingestion 158 (9.6%). Upon reviewing the consultation records related to foreign body ingestion, the most common location was the stomach, and consultations were most frequently due to ingestion of coins, toy parts, and batteries. The third most common reason for consultation was trauma in 117 (7.1%) patients and scrotal pain/swallowing in 102 (6.2%) (Table 2). Among the pediatric surgery consultations requested by PED, the indication for PS consultation was appropriate for both departments in 803/1639 patients (appropriateness rate=49%) (Table 3).

Multivariable logistic regression analysis identified several independent predictors of inappropriate pediatric surgery consultations. Nighttime consultation requests were significantly associated with higher odds of being deemed inappropriate compared to daytime consultations (OR 2.4, 95% CI 1.8–3.2, P<0.001). Younger patient age (<5 years) was also an independent predictor (OR 1.6, 95% CI 1.2–2.1, P=0.002). Among preliminary diagnoses, abdominal pain or suspected appendicitis showed the strongest association with inappropriate consultations (OR 3.1, 95% CI 2.2–4.4, P<0.001). Sex and hospital site were not significantly associated with consultation appropriateness in the adjusted model. These findings indicate that timing of consultation, age, and preliminary diagnosis are the main factors influencing the appropriateness of pediatric surgery referrals (Table 4).

When the consultation responses of 1639 patients were examined, it was found that 836 patients were not considered appropriate for PS consultation by the department, and pediatric evaluation was recommended. Statistical comparison of these data with the consultation time revealed that nighttime consultations were significantly less likely to be deemed appropriate (652/1102 patients) (P<.00001).

Among the inappropriate consultations, comparison of preliminary and final diagnoses revealed that the most frequently recommended conditions for pediatric evaluation were abdominal pain/appendicitis/ileus/volvulus/cholecystitis in 332/760 cases (43%), trauma in 52/117 cases (44%), and caustic ingestion in 45/70 cases (64%) (Table 5).

Discussion

Pediatric emergency department visits have been steadily increasing worldwide [12,13]. The most common reasons are breathing difficulties, fever, general illness, diarrhea and/or vomiting, abdominal pain, and extremity injuries [14,15]. Notably, approximately one-third of these visits were reported as unnecessary or inappropriate [16].

A similar pattern has been observed in adult emergency settings. For instance, a study conducted at the Royal London Hospital revealed that 64.4% of adult emergency admissions were related to nontraumatic abdominal surgical conditions. Surgical diseases are known to contribute significantly to the global disease burden and constitute a major part of the workload of surgeons in many regions [17].

To the best of our knowledge, the present study is the first to specifically examine the pediatric surgery workload originating from consultations requested by PEDs. The consultation rate from PED to pediatric surgery was 3.1%, highlighting the considerable role of emergency consultations in the surgeons’ daily clinical responsibilities. In a study published by Busca et al in 2014, which analyzed 628 000 adult emergency department visits, the most frequently requested consultations were orthopedics (5.1%), followed by psychiatry (3.0%) and general surgery (2.9%) [18]. Compared to this, the 3.1% consultation rate to pediatric surgery, given the limited number of specialists in the field, indicates a substantial burden.

In our study, 1099 consultations (67%) were requested during nighttime shift hours. Among these, 652 consultations (59%) were considered inappropriate, indicating a significant association between consultation timing and appropriateness. This may be explained by the relatively limited clinical experience of night-shift personnel and the reduced availability of senior physicians for supervision or guidance before consultation. Supporting this, a study by Ygiyeva et al involving paramedics demonstrated similar findings regarding off-hour clinical decision-making among less experienced staff [19].

Owing to the shortage of pediatric emergency medicine specialists, most PEDs are staffed by a limited number of pediatricians and emergency physicians, with a larger proportion of general practitioners. The increasing patient burden cumulatively results in higher consultation rates, longer hospital stays, unnecessary diagnostic testing, and greater workload and burnout among healthcare personnel [20–22]. In our study, 51% of the consultations requested by PEDs were ultimately concluded with recommendations involving pediatric follow-up or general pediatric evaluation. This suggests potential educational or conceptual challenges in distinguishing between pediatric medical and surgical conditions. Additionally, the tendency to share responsibility for patient management may reflect gaps in knowledge or clinical experience among attending physicians.

Abdominal pain, accounting for approximately 6% to 10% of PED visits [23,24], is one of the most frequently encountered concerns. Constipation has been reported as the underlying cause in about 11% of these cases [25]. In our study, abdominal pain or suspected appendicitis was the preliminary diagnosis in 43% of the pediatric surgery consultations. Among these patients, 24% were diagnosed with and treated for constipation, 20% underwent appendectomy, and 12.9% were admitted for inpatient care. In the remaining 41% of patients, a pediatric evaluation was recommended. These findings are consistent with a 2023 study by McNulty et al, which reported that 41% of 381 patients referred for a preliminary diagnosis of appendicitis were not ultimately diagnosed with appendicitis [26]. This highlights the significant role of constipation, a condition that is easily managed in primary care, in contributing to the pediatric surgery consultation workload.

For this study, hospitals were selected from academic medical centers based on the assumption that a higher level of training among staff would correlate with better outcomes. Two university hospitals from different cities with established pediatric emergency and pediatric surgery departments were included. The primary aim of this study was to assess the burden placed on pediatric surgery by PED consultations, an aspect not previously analyzed in the literature. Given the global shortage of pediatric surgeons and the tendency for this specialty to be less frequently chosen due to the high workload, these findings are of particular importance.

Considering that the average number of daily consultations was 4 and that approximately half may be considered inappropriate based on our findings, it is imperative that national and international pediatric surgery associations play a leading role in addressing the resulting workload and burnout. To mitigate this issue, standardized pediatric surgery emergency algorithms should be actively implemented, particularly in training hospitals and peripheral centers with less experienced emergency physicians. Furthermore, the latest developments in artificial intelligence (AI) and machine learning models in general pediatric surgery, as well as recent initiatives such as AI integration in pediatric surgery, are bridging innovation, equity, and adaptive decision-making, showing the potential of AI-supported programs [27]. The integration of these tools, particularly in pediatric emergency departments, may provide innovative and equitable solutions to reduce inappropriate consultations and contribute significantly to alleviating pediatric surgery burnout.

One limitation of this study is its 2-center design, which restricts the generalizability of its findings to a broader international context. Nevertheless, as the first study of its kind, this may serve as a reference point and foundation for future international research. In light of the growing global population and the declining number of pediatric surgeons, the challenges outlined in this study that directly contribute to the increasing pediatric surgical workload should be addressed proactively before they become even more critical in the years to come.

Conclusions

This study sheds light on an overlooked aspect of pediatric surgical workload by quantitatively evaluating consultation patterns originating from pediatric emergency departments. The findings reveal not only the frequency of these consultations but also the high proportion of those deemed inappropriate, particularly at night. This has significant implications for clinical efficiency, healthcare costs, and physician wellbeing. As the number of pediatric surgeons continues to decline globally, addressing the root causes of unnecessary consultations such as training gaps and triage inefficiencies has become increasingly urgent. Multicenter international studies are warranted to validate these findings and inform the development of standardized, evidence-based consultation algorithms.