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Table of Contents
Year : 2023  |  Volume : 28  |  Issue : 2  |  Page : 145-149

Demand for plastic surgery services via inpatient referrals in a Nigerian Teaching Hospital

Department of Surgery, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria

Date of Submission16-Sep-2022
Date of Decision20-Nov-2022
Date of Acceptance18-Dec-2022
Date of Web Publication21-Mar-2023

Correspondence Address:
Obinna R Okwesili
Department of Surgery, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmh.IJMH_60_22

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Background: Plastic surgery is one of the most collaborative surgical specialties and is also considered the most consulted service in a hospital. Plastic surgeons respond to many medical consults or inpatient referrals, and the comprehensive impact of these services, when they are nonoperative, often goes unnoticed. Objectives: The objectives of the study were to assess the nature of demands of plastic surgery services for admitted patients in a teaching hospital and the specialties and types of patients that benefit from them. Materials and Methods: Clinical records of inpatients evaluated by plastic surgeons were retrieved using a compendium of consults received from other specialties within the hospital over a period of 1 year period. Results: The plastic surgeons received a total of 151 hand-written consults from surgeons, physicians, gynecologists, and pediatricians. The vast majority came from physicians (45.7%) and surgeons (40.4%). Among the physicians, endocrinologists sent the highest number of consults (42.5%). Ulcers constituted the commonest reason for inpatient referrals (66.2%). Over 29% of consults were for patients with primary diagnosis of diabetes mellitus, whereas 13.9% were for head injuries. Conclusions: The demands for the services of plastic surgeons come from virtually all the clinical specialties in a tertiary hospital. The commonest reason for such referral is for their review and management of ulcers. There is a need to utilize telemedicine in reducing the burden of reviewing these patients, especially in large tertiary hospitals.

Keywords: Inpatient referrals, medical consult, plastic surgery services

How to cite this article:
Achebe UJ, Okwesili OR, Onumaegbu OO. Demand for plastic surgery services via inpatient referrals in a Nigerian Teaching Hospital. Int J Med Health Dev 2023;28:145-9

How to cite this URL:
Achebe UJ, Okwesili OR, Onumaegbu OO. Demand for plastic surgery services via inpatient referrals in a Nigerian Teaching Hospital. Int J Med Health Dev [serial online] 2023 [cited 2023 May 28];28:145-9. Available from: https://www.ijmhdev.com/text.asp?2023/28/2/145/372152

  Introduction Top

Plastic surgery is one of the most collaborative surgical specialties and the most consulted service in a hospital.[1] Plastic surgeons respond to many medical consults (or inpatient referrals). The comprehensive impact of these services, when they are nonoperative, often goes unnoticed because no economic value is placed on them in a “government” or teaching hospital.[2] Inpatient referrals are a means of requesting for a review of a patient on admission by another specialty in order to give advice on the care of the patient, to co-manage the patient, or to fully take over the patient’s management. Different methods are used for the consults[3],[4] including hand-written letters, but electronic consults (e-referral) has been introduced to decrease delivery time and standardize information contained in it.[4],[5],[6] The electronic consults we use in our hospital include phone calls, phone SMS, and WhatsApp messages. In some institutions, the use of e-mails and pagers is also common.[3]

The current trend in the management of these patients is toward interdisciplinary teamwork. These programs are not well established in developing countries,[2] but this trend is rapidly changing in our subregion. This interdisciplinary approach offers patients a variety of options of the management of their conditions.[3],[7] The options chosen for the patients are planned for their benefit, and this influences the compliance of patients to the management plan. This approach is useful both in medical and surgical management of patients. Plastic surgeons usually offer services to a number of patients admitted primarily by other specialties[8] and are frequently involved in joint surgical management of patients. It has been noted that about 10% of operations by plastic surgery departments were on patients from wards of other departments and 10% of the operations were combined operations with surgeons from other specialties.[9] These make it difficult to accurately evaluate the impact of plastic surgery services on a health system.[2]

Many consultations plastic surgery receives involve the assessment of wounds.[1] In our hospital, a majority of these medical consults were related to wounds. Nearly all of such wounds reviewed required and benefitted from subsequent re-reviews by the Plastic Surgery Unit. These follow-up reviews were not prompted by further consults.

The Plastic Surgery Unit and specialty was established in our teaching hospital in April 2008. This was, therefore, a review of the services of the unit when it was only 4-year-old in the hospital. The hospital has about 500 beds and offers services at a tertiary level to patients from the state it is located in and from the neighboring states.

  Materials and Methods Top

This was a review of all the medical consults received by plastic surgeons from different specialties in our teaching hospital over a period of 1 year, from December 1, 2011, to November 31, 2012. Ethical approval for the study was obtained from the University of Nigeria Teaching Hospital (UNTH) Ethics Committee (application reference no: NHREC/05/01/2008B-FWA00002458-IRB00002323). These include the sex, age, gender, specialty/subspecialty of the unit that sent the consult, the primary diagnosis, and the reason for the consult. For each patient, only one consult was used, even for situations where there were two or more consults received at different times during a particular admission. Consults received from medical officers for the review of patients that presented at the Accident and Emergency Department were excluded. Data analysis was descriptive using the Statistical Package for Social Sciences (SPSS, Chicago, IL, USA) version 20 for Windows. Data were presented by percentages and proportions.

  Results Top

A total of 151 medical consults were received by the two plastic surgery units in our teaching hospital, serving as invitations to review the corresponding number of patients who were admitted under various specialties during the period under review. There were 90 males and 61 females (a ratio of 1.4:1). The inpatients reviewed by plastic surgeons cut across all age groups, from newborns to the elderly patients [Figure 1]. The majority of the consults received was from physicians (medicine) and surgeons, making up 86.1% of all the consults received [Table 1]. The highest number of consults came from subspecialties in medicine (45.7%), followed by surgery (40.4%), and 2.64% of patients came from the obstetricians and gynecologists.
Figure 1: Age distribution of all patients

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Table 1: Distribution of the consults among the specialties

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Consults were received from six surgical specialties [Figure 2]. The greater number was from the neurosurgeons (52.38%), followed by the orthopedic surgeons (16.67%). Among the consults from the physicians, the endocrinologists sent in the highest number (42.5%) and 21.28% of the consults were from the nephrologists [Figure 3]. The balance was from five other specialties.
Figure 2: Consults from different surgical specialties

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Figure 3: Distribution of patients among medical units

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The highest number of consults was in request of preventive measures against pressure sores or to treat preexisting pressure ulcers on admitted patients or incipient sores arising following admission (27.8%) [Table 2]. Another prominent indication for many of the consults was a spectrum of ulcers including diabetic foot ulcers (23.8%), other leg ulcers (5.3%), and ulcers elsewhere on the body (9.3%). Of the four consults received from the gynecologists, three were invitations to review patients with acquired gynetresia for vaginal reconstruction (2%).
Table 2: The reasons for the consult to plastic surgery

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More than one quarter of all the patients involved had diabetes mellitus as their primary diagnosis (29.14%), whereas 13.9% had head injuries of varied severity. The other primary diagnoses include spinal injuries, sepsis, carcinoma of the prostate, cerebrovascular injury, multiple injured patient, hand infections, gun-shot injuries, and open fractures. A majority of the patients referred by the orthopedic surgeons had a primary diagnosis of open tibial fracture.

  Discussion Top

Medical consults in our hospital contain information regarding the identity and, the location of the patient, brief clinical information including the reason(s) for the consult. It does not always have information on the time frame expected for the consultation as is the case for some other consult models.[10] Nevertheless, all consults are expected to be attended to promptly.

The total number of consults received during the period under review was 151. At this time, the Plastic Surgery Unit was barely 4 years old. The number is expected to grow as a greater awareness and understanding of the services offered by plastic surgeons in our hospital becomes rife. In many instances, the number of such patients reviewed by Plastic Surgery Unit on a weekly basis during the period reviewed exceeded the number of patients admitted primarily under them. Plastic surgeons received consults from virtually all the specialties in a teaching hospital and reviewed patients of all ages including newborn babies. When babies are born with congenital deformities such as cleft lip and palate, congenital hand anomalies, or conditions like aplasia cutis congenita, medical consults are written to plastic surgeons to review and to counsel the parents. The spectrum of cases the plastic surgeons were invited for inpatient review differed from the distribution of the cases they managed on outpatient basis or those directly admitted through the clinic. Many of the referrals plastic surgeons receive at the outpatient clinic were for patients without comorbidities such as diabetes and head injuries, while some that had comorbidities that were under control, not requiring admission. These include patients with keloids, contractures, congenital anomalies, cutaneous malignancies, and those in need of esthetic surgeries and others.

Leg ulcers (29.1%), which include ulcers on the foot or leg, were the major reasons for inviting a plastic surgeon within the year under review. Ulcers, in general, including diabetic foot ulcers, pressure ulcers, leg ulcers, and ulcers on other parts of the body made up 66.2% of the diagnoses that informed a medical consult to the plastic surgeons. The ulcers on the other parts of the body included malignant ulcers and ulcers resulting from trauma. A majority of consults for the review of pressure ulcers were for patients newly admitted into the emergency ward. Most of these patients had the pressure ulcers before admission, and many were bedridden by medical conditions such as diabetes, stroke, etc. The care-givers of these patients were usually aware of the need to turn the patients frequently (every 2 h or less) but failed to comply fully. It is necessary to employ health attendants whose duties should include regular and frequent turning of these patients. These would also be useful in helping the nurses in turning the patients when they are on admission. The rate of patients developing pressure sore in a hospital is one of the indices of accessing the level of nursing care offered.

The highest number of consults came from specialties in medicine (45.7%). Most of these were from the endocrinologists (42.53% of physicians). A majority of these consults were for patients with diabetes as primary diagnosis (29.14%) or those who developed diabetic foot (23.8% of all patients).

Some of the patients reviewed following a consult to our Plastic Surgery Unit required us to determine the appropriate dressing agent and the mode and frequency of dressing. In such cases as these, telemedicine will be useful in reviewing these patients, thereby reducing the time and energy spent in physically going to see them.[11] The tools of telemedicine have been found useful in engaging the services of plastic surgeons, in acute cases.[12] This can be extended to the management of inpatients.

  Conclusions Top

There are various demands for the services of plastic surgeons for patients on admission in a tertiary hospital. Medical consults came to Plastic Surgery Units from virtually all the clinical specialties and subspecialties in our hospital, especially from neurosurgeons, orthopedic surgeons, and endocrinologists. The consults were for patients that cut across all ages and were in virtually all the wards in the hospital. The commonest indication for inpatient referral was ulcer, especially leg ulcer (involving the foot or leg). There is a yawning need to employ telemedicine in reducing the burden of reviewing patients on admission in all sectors of the hospital, especially so in large teaching hospitals.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Wang TY, Serletti JM, Kolasinski S, Low DW, Kovach SJ, Wu LC A review of 32 free flaps in patients with collagen vascular disorders. Plast Reconstr Surg 2012;129:421e-7e.  Back to cited text no. 2
Matsuo T, Hayashi K, Uehara Y, Mori N Essential consultants’ skills and attitudes (willing CONSULT): A cross-sectional survey. BMC Med Educ 2021;21:366.  Back to cited text no. 3
Kim-Hwang JE, Chen AH, Bell DS, Guzman D, Yee HF Jr, Kushel MB Evaluating electronic referrals for specialty care at a public hospital. J Gen Intern Med 2010;25:1123-8.  Back to cited text no. 4
Shephard E, Stockdale C, May F, Brown A, Lewis H, Jabri S, et al. E-referrals: Improving the routine interspecialty inpatient referral system. BMJ Open Qual 2018;7: e000249.  Back to cited text no. 5
Azamar-Alonso A, Costa AP, Huebner LA, Tarride JE Electronic referral systems in health care: A scoping review. ClinicoEcon Outcomes Res 2019;11:325-33.  Back to cited text no. 6
Alderman AK, Hawley ST, Waljee J, Morrow M, Katz SJ Correlates of referral practices of general surgeons to plastic surgeons for mastectomy reconstruction. Cancer 2007;109:1715-20.  Back to cited text no. 7
Raine R, Xanthopoulou P, Wallace I, Nic A’ Bháird C, Lanceley A, Clarke A, et al Determinants of treatment plan implementation in multidisciplinary team meetings for patients with chronic diseases. BMJ Qual Saf2014;23:867-76.  Back to cited text no. 8
Pers M, Davenport P Plastic surgery in a large hospital. Br J Plast Surg 1981;34:373-8.  Back to cited text no. 9
Serling-Boyd N, Miloslavsky EM Enhancing the inpatient consultation learning environment to optimize teaching and learning. Rheum Dis Clin North Am 2020;46:73-83.  Back to cited text no. 10
Diver AJ, Lewis H, Gordon DJ Telemedicine and trauma referrals—A plastic surgery pilot project. Ulster Med J 2009;78:113-4.  Back to cited text no. 11
Dobke MK, Bhavsar D, Herrera F Do telemedicine wound care specialist consults meet the needs of the referring physician? A survey of primary care providers. Int J Telemed Appl 2011;2011:321376.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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