Original Paper
Received: April 2, 2003
Eur Neurol 2003;50:207214
DOI: 10.1159/000073861
Impact of Emergency Room
Neurologists on Patient Management
and Outcome
Thierry Moulin a Denis Sablot a Elisabeth Vidry a Faouzi Belahsen a
Eric Berger a Patrick Lemounaud b Laurent Tatu a Fabrice Vuillier a
Anne Cosson a Eugeniu Revenco a Gilles Capellier b Lucien Rumbach a
a Department of Neurology and b Emergency Care Unit, University Hospital, Besanon, France
Key Words
Emergency room care W Epilepsy W Neurological
examination W Stroke outcome
Abstract
The frequency and impact of in-patient assessment by a
neurologist in the emergency room (ER) setting remain
largely underestimated. The objective of our study was
to analyse the impact of neurologist in-patient manage-
ment. Methods: Over a period of 12 months, we prospec-
tively recorded the demographics of patients requiring
examination in the ER, the ER teams tentative neurologi-
cal diagnosis, the neurology teams final diagnosis and
patient outcomes. The time interval between admission,
call for a neurologist and the assessment by the neurolo-
gist were recorded. Results: Assessments by neurolo-
gists were performed in 14.7% (1,679/11,421) of all pa-
tients admitted to the ER. The mean time between
admission and examination was 32 (B 36) min, irrespec-
tive of the day of the week, and dependent on the tenta-
tive diagnosis: shorter for stroke and status epilepticus
(p ! 0.05) and longer for confusion and vertigo (p !
0.05). The initial causes for examination were: stroke
2003 S. Karger AG, Basel
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Accepted: June 26, 2003
(33.1%), epilepsy (20%), loss of consciousness (9%),
headaches (9%), confusion (5.4%), peripheral nervous
system disorders (4.4%), vertigo (4.2%), cognitive dys-
functions (4%), gait disorders (3.2%) and miscellaneous
(7.1%). Overall, false positive or negative diagnoses
were produced by the ER in 37.3 and 36.6% of ER admis-
sions, respectively. A complete change of diagnosis by
the neurologist was found in 52.5% of patients. Of the
patients undergoing a neurological examination, 18.4%
were able to go home, 31.8% were admitted to the stroke
unit, 32.4% to the general neurology unit and 17.4% to
other departments. Conclusion: Our study stresses the
need for a neurologist in the ER, both in quantitative
terms and for the benefit of patient management.
Copyright 2003 S. Karger AG, Basel
Introduction
While out-patient management for chronic neurologi-
cal disorders is now well established for most of the main
neurological diseases, the impact of a neurological in-
patient assessment on diagnosis, patient management and
treatment in the emergency room (ER) remains largely
Thierry Moulin, MD, PhD
Service de Neurologie
CHU Jean Minjoz
FR25030 Besanon (France)
Tel. +33 3 81 66 82 36, Fax +33 3 81 66 84 70, E-Mail thierry.moulin@univ-fcomte.fr
underestimated [1, 2]. Neurological emergencies are de-
fined by certain criteria, including rapid onset, immediate
poor prognosis, and the requirement for prompt resuscita-
tion. These criteria apply to standard neurological emer-
gencies, i.e. generalised status epilepticus (SE) and respi-
ratory failure due to neurological diseases. However, re-
cent advances in neuroimaging techniques and new ther-
apeutic imperatives make it necessary to establish prog-
nostic factors as soon as possible in order to select the
right treatment for any given patient. Furthermore, the
concept of emergency neurology has evolved to allow bet-
ter preservation of neurological functions by saving as
much cerebral tissue as possible. The role of the neurolo-
gist in the ER is therefore crucial in defining, confirming
and implementing patient management. Stroke diagnosis
has already been shown to exemplify the necessity for spe-
cialised management [3]. Other recent reports emphasis-
ing the specific role of the neurologist in modifying the
tentative diagnosis in neurological emergencies highlight
the apparent complexity of a neurological examination
compared to a cardiological investigation [4].
The aim of our study was to evaluate the need for neu-
rologists in an ER and to determine the impact their pres-
ence has on patient management for every specific neuro-
logical symptom and sign.
Patients and Methods
The University Hospital of Besanon (1,200 beds) serves as a pri-
mary care hospital for a population of about 200,000 people. The ER
is the only unit to manage medical and surgical emergencies in
adults. The Neurology Department is divided into different units,
including a stroke unit. With the progressive development of this
stroke unit since its creation in 1987, the neurology team 4 resi-
dents and 4 senior physicians has structured itself to meet emergen-
cy calls 24 h a day: there is always a resident on duty and a senior
practitioner on call. The shifts for duty are 06.3018.30 h and 18.30
06.30 h. The emergency department has 10 senior physicians certi-
fied for ER care and 6 residents trained to identify vital failures. The
normal admission procedure is to evaluate the degree of vital failure
in every patient, to prescribe the appropriate examinations and ther-
apy according to the diagnostic algorithms and flow charts usually
applied in emergency medicine, and to ensure optimum dispatch-
ing.
For each neurological problem detected in a patient admitted to
the ER, the neurology resident on duty was called and informed of
the ERs tentative diagnosis, the kind and intensity of symptoms or
signs (i.e., onset and course, as well as general demographics). These
calls were systematically made after patients had been examined by
an ER resident and an ER practitioner. The ER physicians were also
asked to give severity criteria based on instruments such as the Glas-
gow Scale (for loss of consciousness) and pre-specified guidelines
(complete or partial) for motor deficits. Following examination by
the resident and/or senior neurologist, the diagnosis was confirmed
208 Eur Neurol 2003;50:207214
or revised by the clinical findings and, if necessary, by neuroimaging
or neuroelectrophysiological examinations (CT, MRI, EEG, EMG,
lumbar puncture). These neurological examinations could not have
been previously conducted by the ER team. For the tentative diagno-
sis, the analyses of these neurological examinations by the ER team
were always taken into account when they were performed before the
neurological assessment. A formal synthesis of all available data was
done in collaboration with the senior neurologist on duty and
approved by the emergency team before a patient was discharged
from the ER.
From January 1st to December 31st, 1997, we conducted a pro-
spective study of the neurological examinations performed in re-
sponse to calls from the ER. Only patients for who assessment by a
neurologist was requested by the ER were included in this study; ER
practitioners were naive of this study. Whereas we did not pre-define
the lists of neurological symptoms and signs, the procedures for neu-
rology patient management (exams and treatment) followed com-
monly used flow charts and diagnostic algorithms. For each patient,
we analysed the demographic data, the time interval between admis-
sion to the ER and the call to the neurologist (emergency reaction
time) and between the emergency call and the assessment by a neu-
rologist (neurological response time), tentative and final diagnoses,
and patient outcome. Analyses of timing, type, and amount of gener-
al (i.e., ECG, blood tests, etc.) or neurological examinations were not
specifically performed. The tentative and final diagnoses were di-
vided into groups according to symptom or syndrome (e.g. headache,
vertigo, loss of consciousness, focal deficits, gait disorders) or, when
possible, into nosologic groups (e.g. stroke, epilepsy, multiple sclero-
sis). For the nosologic groups, classic neurological criteria were used,
such as clinical findings and neuroimaging for stroke, tumour, etc.
Final diagnosis was determined again by the neurology team in daily
case review meetings during which the impact of the neurologists
act(s) was evaluated.
The neurological impact was analysed in two complementary
ways. Firstly, it constitutes what we called the general neurological
contributive effect. It was a general and subjective evaluation of neu-
rologists actions in the ER, considered as (1) just confirmative when
no modification in diagnosis or management was proposed to the ER
physicians; (2) additional when the tentative diagnosis was con-
firmed in the same nosologic group, allowed a more accurate analysis
of neurological examinations, additional patient management or
even when neurologists specifically asked for new neurological exam-
inations, and (3) complete when the tentative diagnosis was totally
changed, e.g. syndromes or symptoms in a clear nosologic group
(from dysarthria, confusion to stroke or from syncope to seizure, ...)
or in a different group (i.e. from epilepsy to stroke, from transient
ischemic attack to ischemic stroke), or when it resulted in active ther-
apeutic measures that potentially modified patients outcome, such
as antiepileptic drugs, anticoagulants or decision for surgery. Sec-
ondly, with the same amount of information (clinical and neurologi-
cal examinations), we grouped the quality of the ER tentative diagno-
sis into 3 categories: correct diagnosis, false positive or false negative
diagnosis. All data were prospectively coded using a pre-specified
form after each period of duty.
Statistical analyses were performed using the statistic software
SPSS. Data were considered significantly different if p ! 0.05.
Moulin et al.
Fig. 1. Comparison between the different
response times, periods of the day and days
of the week. a Significant differences for the
different types of response times: shorter
neurological response times after 18.30 h
(a 27.2 vs. 36.1 min, p ! 0.01) and longer
emergency response times after 18.30 h
(b 67.5 vs. 81.1 min, p ! 0.01). b Constantly
and significantly shorter neurological re-
sponse times after 18.30 h throughout the
week. * p ! 0.05.

Results sciousness (87.5 min, p ! 0.05), vertigo (90.5 min, p !

Evaluation of Neurological Acts in the Emergency
Room
A neurologist was called to examine 1,679 of the
11,421 patients admitted to the ER (14.7%). Fifty-two
percent of the examined patients were male, the mean age
was 56.9 B 21 years.
Almost 10% (9.4%) of the neurological examinations
took place at night (00.006.30 h), 18.3% in the morning
(6.3012.00 h), 38% in the afternoon (12.3018.30 h) and
34.3% in the evening (18.3024 h). The emergency reac-
tion time (73.4 B 70.4 min) depended on the tentative
diagnosis; it was shorter for stroke (66.9 min, p ! 0.03)
and SE (68.1 min, p ! 0.05), and longer for loss of con-
0.01) and confusion (110.5 min, p ! 0.01). The neurologi-
cal response time was 32.2 B 36.1 min irrespective of the
day of the week. Significant differences in reaction times
were observed between the different periods of duty (be-
tween 06.30 and 18.30 h and after 18.30 h), as shown in
figure 1.
Contribution of the Neurologist in the Emergency
Room
Global Evaluation
The main tentative diagnoses are shown in table 1.
Examination by a neurologist led to a positive contribu-
tion in 87.6% of the patients over all (additional in 35.1%
and complete in 52.5%). The positive effect of the neurol-

Impact of Emergency Room Neurologists Eur Neurol 2003;50:207214 209

on Patient Management and Outcome
 Table 1. Distribution of the tentative and final diagnoses and results of the neurological contributive effect according
to the different final diagnoses

Tentative Final Global neurological

diagnoses diagnoses contributive effect, %
(n = 1,679), % (n = 1,679), % confirmative/additional/complete

Stroke 556 (33.1) 567 (33.8) 13.6/48.8/37.6

Epileptic seizures 336 (20) 349 (20.8) 8.3/69.9/21.8
Headaches 151 (9) 117 (7) 8.5/63.2/28.2
Loss of consciousness 151 (9) 94 (5.7) 4.3/58.5/37.2
Confusion 90 (5.4) 95 (5.7) 1.1/26.3/72.6
Peripheral neurological disorders 74 (4.4) 72 (4.3) 56.9/11.1/45.8
Dizziness-vertigo 71 (4.3) 21(1.3) 0/95.2/4.8
Cognitive dysfunctions 67 (4) 77 (4.6) 32.5/11.7/55.8
Gait disorders 39 (2.2) 37 (2.2) 21.6/54.0/24.4
Multiple sclerosis 39 ( 2.3) 43 (2.6) 25.6/58.1/16.3
Neurological coma 27 (1.6) 5 (0.3) 0/20.0/80.0
Infectious diseases 32 (1.9) 24 (1.4) 29.2/4.1/66.8
Psychiatric disorders 21 (1.3) 43 (2.6) 12.6/11.6/76.8
Subdural hematoma 10 (0.7) 22 (1.3) 0/13.6/86.4
Brain tumour 1 (0.1) 36 (2.1) 0/14.3/85.7
No neurological disturbances 0 77 (4.6) 0/0/100
Miscellaneous 2 (0.1) 0

ogist was strongest when stroke, confusion or coma were
suspected (86.4, 98.9, 100%, respectively), as shown in
table 1. It was poorest when tentative ER diagnoses were
very precise, as was the case with migraine in 20% (1 of 5
affected patients), global transient amnesia in 28% (4/14
patients), dementia in 26.3% (5/19 patients) or SE in 50%
(3/6 patients).
False positive or false negative diagnoses were pro-
duced by the ER team in 37.3 and 36.6% of all patients,
respectively; and their tentative diagnosis was correct in
only 26.1%. The different percentages of false negative,
false positive or correct diagnoses for specific symptoms,
syndromes or nosologic groups are shown in figure 2.
Only 64.2% (1,078/1,679) of the patients were admit-
ted to a neurology unit following assessment by a neurolo-
gist: 31.8% to the stroke unit and 32.4% to the general
neurology unit. Of the remaining 35.8% (601/1,679 pa-
tients), 17.4% were directed to other departments, includ-
ing 5% to the intensive care unit and 2.5% to neurosurge-
ry, while 18.4% were able to go home. Of the patients dis-
charged (309/1,679), the distribution of final diagnoses is
shown in figure 3.
Specific Insights
Stroke. In 567 patients the final diagnosis was stroke or
TIA. A false positive tentative diagnosis of stroke had
been made prior to examination by the neurologist in 124
of the 556 (22.3%) patients with this tentative diagnosis.
The main final diagnoses for these 124 patients were: epi-
lepsy in 20.1% (25 patients), tumour in 12.9% (n = 16),
cognitive dysfunction in 14.5% (n = 18), and confusion in
10.4% (n = 13). A false negative diagnosis of stroke had
been made in 23.8% (135 patients). The tentative diag-
noses in these cases were: vertigo in 22.2% (30 patients),
cognitive dysfunction in 16.2% (n = 22), peripheral ner-
vous system disorder in 14.1% (n = 19), epilepsy in 12.5%
(n = 17), confusion in 11.1% (n = 15) and isolated head-
aches in 8.9% (n = 12).
Epileptic Seizures. Epileptic seizure was the final diag-
nosis in 349 patients. Sixty-three patients (18.7%) had
had a false positive tentative diagnosis of epilepsy, of
which 44.4% (28 patients) had a final diagnosis of confu-
sion, 19% (n = 12) syncope, 11.1% (n = 7) stroke and
11.1% (n = 7) a tumour. Seventy-six patients (21.8%) had
had a false negative diagnosis of epilepsy. The tentative
diagnosis was syncope in 50% (n = 38), stroke in 32.9%
(n = 25) and confusion in 10.5% (n = 8). SE was observed
in 5.5% of epileptic patients (n = 19). Unfortunately, the
tentative diagnosis was ascertained in only 3 of them
(15.8%). The main false negative diagnosis, correspond-
ing to 84.2% of SE, was poor evaluation of seizure in
68.8% (n = 11 patients), confusion in 18.7% (n = 3), par-

210 Eur Neurol 2003;50:207214 Moulin et al.

Fig. 2. Comparisons between the percentage
of false negative or false positive diagnoses
and the correct tentative diagnoses for each
category of signs, symptoms and syndromes
(figures within the diagram are absolute
numbers).
kinsonian tremor in 6.3% (n = 1) and subdural haemato-
ma in 6.3% (n = 1).
Headaches. Headaches motivated the assessment by a
neurologist in 151 patients (9%). The main distribution of
the tentative diagnosis was: headaches with no further
details in 62.2% (n = 94), subarachnoidal haemorrhage
(SAH) in 12.5% (n = 19), migraine or cluster headaches in
3.9% (n = 6) and miscellaneous (intracranial hyperten-
sion, orthostatic, psychological or tension headaches) in
21.1% (n = 32). Of the 19 patients suspected to have SAH,
the diagnosis was evident in only 47.4% (9/19 patients).
In the remaining 52.6% (10/19 patients), the diagnosis of
SAH was not confirmed (false positive patients). Seven of
these patients had migraine, 1 meningitis, 1 was in meta-
bolic coma and 1 had stroke. On the other hand, 6 of the
15 patients (overall) with true SAH (40%) were not clearly
Impact of Emergency Room Neurologists
on Patient Management and Outcome
and clinically identified (false negative patients). The ten-
tative diagnoses for these patients were: confusion in 2
patients, migraine in 2, stroke in 1 and coma in 1.
Confusion. Ninety patients were tentatively diagnosed
with confusion. The neurologist confirmed this diagnosis
in only 28.9% (26/90 patients). The other tentative diag-
noses (false positive) were: degenerative disorders in 20%
(dementia in 11 patients, transient global amnesia in 3,
parkinsonism in 4), stroke in 16.7% (15 patients), epilep-
tic seizure or SE in 10% (5 and 3 patients, respectively),
SAH or subdural haematoma in 5.6% (5 patients), psy-
chiatric disorders in 6.7% (n = 6), normal neurological
examination in 7.8% (n = 7) and miscellaneous in 5.5%
(cerebral tumour in 1 patient, metabolic coma in 1,
encephalitis in 3). Among the 95 patients with a final
diagnosis of confusion, the main aetiologies were: meta-
Eur Neurol 2003;50:207214 211

Fig. 3. Black bars represent the percentage
distribution of the final diagnosis (by symp-
tom or syndrome and based on the neurolog-
ical examination) of the 309 patients dis-
charged directly from the ER. Grey bars
represent the percentage of discharged pa-
tients with a given symptom or syndrome in
relation to the total number of patients with
the same symptom or syndrome.
bolic disorders in 10.5% (10/95 patients), acute alcohol-
ism in 5.2% (5/95), hypoglycaemia in 11.6% (11/95), ther-
apeutic intoxication in 21% (20/95), infection or fever in
21% (20/95) and dementia in 30.5% (29/95).
Discussion
There is little data on the contribution of the neurolo-
gist in the ER despite the fact that neurological emergen-
cies represent approximately 15% of admissions to the
ER [5]. Most of the studies concern a specific category of
neurological emergency, such as stroke, epilepsy, or head-
ache [14]. The emergency unit at Besanon University
Hospital is the only one for adults in the city and as such
must deal with all neurological conditions. Some 15%
(14.7%) of emergency admissions are related to a neuro-
logical dysfunction. It is to be noted that there may be a
certain bias, as neurologists were undoubtedly called to
see some patients in whom a neurological problem had
212 Eur Neurol 2003;50:207214
ur
already been detected. This does not imply that all neuro-
logical patients admitted to the ER were assessed by a
neurologist, although this is the usual procedure in our
hospital to minimise risk. Moreover, ER physicians were
not aware of the study so that they would not change their
usual calling behaviour. Additionally, our study took a
pragmatic approach in order to analyse the potential and
different impacts of neurological problems in an ER. A
neurologist clearly needs to have specific training in neu-
rological emergencies [6, 7].
Our study found that neurological intervention in the
ER led to a complete contribution in 52.5% of the cases.
This global contribution might well appear to be overesti-
mated if the role of the neurologist was limited only to the
neurological examination and did not include placing
examination results in an overall neurological line of rea-
soning. Moreover, the benefits of these examinations
clearly increase after a patients assessment by a neurolo-
gist, and not only in terms of a positive contribution to
technical investigations. This is especially true for correla-
Moulin et al.
tions between clinical examinations and EEGs [8] and
between clinical examinations and CT scans [9]. While
the neurologist often does not influence decision-making
in neuro-traumatology, his specific role appears essential
in all neurological pathologies for which clinical deduc-
tion is fundamentally relevant [6, 10]. Thus our auto-eval-
uation during the final synthesis was obviously subjective.
The neurological impact in the ER would have been better
analysed by a direct comparison between our ER perfor-
mance and no neurological interventions in the ER. On
the other hand, we unfortunately did neither determine
the degree of impact for each and every act, especially
when neurological examinations were needed, nor their
individual benefits. However, the high rates of false nega-
tive and positive diagnoses (37.3 and 36.6%, respective-
ly), whatever the different groups of signs or syndromes,
also highlight the specificity of the neurological evalua-
tion. It was also interesting to note that the so-called tenta-
tive diagnoses of the ER team were in part only signs and
symptoms and not a proper diagnosis including all ele-
ments in a formal synthesis. Finally, the contribution of
the neurologist to patient management is difficult to
determine because it can also depend on the neurological
training, experience and competence of each ER physi-
cian. They, too, emphasise the need to implement collabo-
rative procedures between neurologists and the ER team
using upgraded algorithms and patient management, as
described in neurology guidelines [11].
The fact that examinations took place during the night
(18.3006.30 h) for 43.7% of patients, regardless of the
day of the week, stresses the need for a neurologist 24 h a
day. The fact that the mean interval between the time
neurologists were called and their first act in the ER was
about 30 min highlights the importance of their availabili-
ty. However, the reaction time before this call (1 h)
depended largely on the tentative diagnosis. Both of these
intervals indicate the loss of time that needs to be recov-
ered, especially in the case of thrombolytic therapy for
stroke patients (which should be initiated within the first
3 h [5, 12, 13]) or in patients with SE [14]. On the other
hand, the assessment by a neurologist also made it possi-
ble to redirect more than one third of the patients admit-
ted to the ER (17.4% were sent to another unit and 18.4%
discharged). This effect, already demonstrated in the
management of an ageing population [15], stroke [16],
headaches [17], confusion [18], and non-convulsive SE
[19], does seem particularly efficient when seen in the per-
spective of reducing length of hospital stay and improving
cost efficiency and the quality of healthcare.
Impact of Emergency Room Neurologists
on Patient Management and Outcome
The assessment by a neurologist in the ER is the first
step. Neurological monitoring then has to be pursued in
the designated neurology unit before the neurologist takes
charge of implementing the appropriate follow-up. Im-
proved mortality and morbidity rates epitomise the effi-
ciency and benefits of stroke patient management in a
stroke unit [20]. In our series, only one third of the
patients admitted to our stroke unit had a consistent diag-
nosis and clear indications for patient management. Cor-
rect early diagnosis also improves the cost/benefit ratio of
the stroke unit, as shown in the Lille experience, where up
to 15% of the patients with no stroke were mistakenly
admitted to this unit [4]. Other studies have reported sim-
ilar errors in 1.519% of cases [16, 21]. In our study, a
false positive diagnosis of stroke or TIA was suspected in
22.3% of our cases. Inversely, the diagnosis was not sus-
pected in 23.8%. In such circumstances, when the exper-
tise required for correct diagnoses and immediate access
to the best-suited treatment, such as thrombolysis, are not
applied, the chance for improvement can be missed.
Moreover, efficient and experienced clinical examination
for early CT scan signs allows for better therapeutic deci-
sions about anti-thrombotic drugs [22, 23].
Epileptic seizures also show the contribution of the
neurologist in the ER. Neurological evaluation allows
patients to be discharged quickly, as was the case for
25.9% of all our discharged patients. In addition, the neu-
rologist should be able to improve the management of epi-
leptic patients, especially those with SE, which was cor-
rectly diagnosed in only 15.8% of our patients [8]. Head-
aches are frequently clarified by emergency neurological
examination, in a proportion varying from 9.3 to 16% in
recent reports close to the rate found in our series (9%)
[24, 25]. While migraine and tension headaches have a
benign prognosis, SAH clearly requires careful attention
with respect to specific management. Interestingly, the
7.5/100,000 incidence rate found in our series seems to
correspond to rates published previously in European
countries (411%) [26]. Surprisingly, our results showed
that a clear clinical diagnosis for SAH was not the rule
(only 47.4% of our patients), contrary to the high rate
(87%) reported by Ferro et al. [27]. On the other hand, the
number of false negative patients (40%) does indeed high-
light the utility of neurological specificity. Acute confu-
sion is a non-specific syndrome that is probably over-used
for neurological disturbances [18]. Our study confirms
this with a low rate of correct diagnoses (23%). Important
diagnoses, such as epileptic seizures (41%), non-convul-
sive SE (10%), stroke (16.7%) and, surprisingly, SAH
(5.6%) have too frequently been diagnosed [28]. All of
Eur Neurol 2003;50:207214 213
these examples emphasise the important prognostic con-
sequences and the potential medico-legal implications.
The neurologist does have a major role in the ER, as has
been underlined by guidelines in the management of neu-
rological emergencies [29, 30].
In conclusion, our study stresses the need for a neurolo-
gist in the ER setting, both in quantitative terms and for
the benefit of patient management and neurological fol-
low-up. This also emphasises the importance of specific
training to reinforce the links between ER and neurology:
the ER physician needs to be trained in neurology and the
neurologist needs emergency training.

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