When Are Inpatient and Emergency Dermatologic Consultations Appropriate?
Practice Points
- Primary inpatient teams should call patients’ insurance companies to verify in-network dermatologists for eventual outpatient follow-up.
- Chronic skin problems (eg, psoriasis, hidradenitis suppurativa) are better cared for in an outpatient setting due to the necessity for follow-up reassessments.
- There remains a need to fill knowledge gaps for common inpatient dermatologic problems that do not necessitate consultations, such as morbilliform drug rash and other chronic and unchanged dermatoses.
In a 2018 article,6 it was postulated that quicker diagnosis of pseudocellulitis and initiation of antibiotics to treat this condition would save the US health care system $210 million annually. We believe that pseudocellulitis would be best evaluated by inpatient dermatology teams, thereby avoiding costly dermatologic consultations, at an average rate of $138.89.6
Morbilliform drug eruptions are among the most common skin conditions seen in the hospital; approximately 95% of cases are an uncomplicated reaction to a medication or virus. Data show that many of these consultations might be unnecessary.7
Our institution (Hackensack University Medical Center, New Jersey) is a tertiary hospital that also is connected with a major cancer center. Given this connection, skin eruptions due to chemotherapy and radiation are common. The treatment of drug eruptions, graft-vs-host disease, and other oncologic or drug-related eruptions should be within the scope of practice of our hospitalists, but these cases frequently involve dermatologic consultation.
We constructed a consultation flowchart (Figure) to help guide the triage of patients in need of dermatologic evaluation by inpatient teams and possibly to avoid unnecessary consultation fees. The manner in which this—or any flowchart or teaching aid—is conveyed to hospital personnel is critical so that these tools are not perceived as patronizing or confrontational. In our flowchart, we list emergent dermatologic conditions that we believe are appropriate for dermatology consultation including erythrodermic psoriasis, bullous pemphigoid flare, and Stevens-Johnson syndrome/toxic epidermal necrolysis.
We believe that the flowchart can educate inpatient medical teams about appropriate dermatology consultation. Use of the flowchart also may decrease unnecessary consultations, which ultimately will lower health care spending overall.
