The hospital complex Santa Casa de Misericordia de Porto Alegre is formed by 7 hospitals in its main location: Hospital Santa Clara for adult assistance; Hospital da Criança Santo Antônio offers pediatric assistance, and other 5 hospitals specialized in cardiology (Hospital São Francisco), neurology and neurosurgery (Hospital São José), pneumology (Pavilhão Pereira Filho), oncology (Hospital Santa Rita) and transplants (Hospital Dom Vicente Scherer).13 The institution provides health assistance for the public health system (Sistema Único de Saúde ‒ SUS), which represents 73% of the total of patients, and for the supplementary health system (health plans and private), corresponding to the others 27%.13

The Dermatology Service consists of more than 40 dermatologists, two postgraduate programs (Residency Program of Dermatology and Specialization Course of Dermatology), and two Fellowships (Surgical Dermatology and Cosmetic Dermatology). The service develops an extensive range of assistance activities such as outpatient consultations, surgeries and cosmetic procedures, and inpatient consultation assistance in all sectors of the hospital complex.13

This descriptive and observational study was performed under a retrospective analysis of hospital referrals and consultations of the Dermatology Service of Santa Casa de Porto Alegre from August 1, 2018, to January 31, 2020. The research was developed in two phases: analysis of referrals of hospital to dermatological consultations (phase 1) and analysis of hospital dermatological consultations (phase 2). From May to December 2021, the authors conducted the data collection through reviews of medical charts and database, utilizing the institution’s information system (Tasy®) as our data source. Fig. 1 represents the flowchart of research methods.

Figure 1.

Flowchart of research methods

* Referrals and consultations performed from August 2018 to January 2020.

(0.38MB).

From the initial data collection, the authors identified 4,719 referrals to dermatological consultations, which were preliminarily analyzed, removing duplicate referrals from the same medical specialty (phase 1). These criteria were adopted due to the substantial number of referrals replicated by mistake or because of duplicate medical prescriptions. Thus, the consultation referrals and their respective medical charts records were analyzed, removing concurrent referrals from different specialties for the same patient, as well as consultations that did not occur due to suspension or loss (phase 2). Therefore, the authors aimed to identify the consultations which were effectively performed by the Dermatology team.

Based on a similar study reported by Huang and Chong,8 the authors arranged the set of variables in two groups: ‘profile of referrals’, hospital sector of origin, referring medical specialty, patient age and gender, clinical data, and diagnostic hypothesis reported by assistant teams; and ‘profile of dermatological consultations’, semiological description, recommended complementary exams, dermatological diagnoses, therapeutic recommendations, and proposed follow-ups.

Regarding the clinical data of referrals, the authors considered four essential clinical variables: morphology of skin lesions, distribution of skin lesions, time of clinical evolution, and diagnosis hypothesis or objective of referral. To systematize and standardize the medical record analysis, the authors classified the dermatologists’ diagnoses into categories and groups according to the International Classification of Diseases (ICD-10). In addition, to measure the repercussion of dermatological consultations, the authors included data from the total number of hospitalizations at the hospital complex and their respective dermatological diagnostic ICDs during the period covered by the study.

About the follow-up recommendations, the authors considered ‘Outpatient follow-up’ those dermatological consultations whose duration of Dermatology assistance was equal to or less than 7 days and with recommendation for outpatient follow-up after completion. On the other hand, ‘Inpatient + outpatient follow-up’ included those consultations whose Dermatology assistance duration was longer than 7 days and with a recommendation for outpatient follow-up after completion. The 7-day cutoff parameter was defined by the authors, based on findings from previous studies,14,15 which revealed means of a length of stay hospitalizations for dermatological conditions ranging from 3 to 10 days, standing out a survey carried out by Orozco et al.,16 which revealed about 90% of dermatological hospitalizations lasted less than 7 days.

The categorical and numerical variables were analyzed descriptively, represented through dispersion measures, and absolute and relative frequencies. The comparative analysis between the groups of variables adopted the Chi-Square test (X²), considering a p-value ≤5% as statistically significant. The authors used the software IBM SPSS Statistics 23 to conduct the statistical data analysis.

Usually, dermatologists work in hospital care in the form of consultations requested by the assistant teams, thus contributing to the diagnosis and clinical management of skin disorders.4,20,21 Consultation referrals must present basic information about the clinical conditions of hospitalized patients,12 considering that the characteristics of the lesions and the clinical evolution are essential elements for the dermatological diagnosis.10

However, despite the relevance of an adequate semiological description, there was a significant lack of data in the analyzed referrals, especially regarding the morphology of skin lesions, converging with previous studies.1,20,22–24 According to Fayne et al.24 and Lorente-Lavirgen et al.,20 non-dermatologist physicians usually describe skin lesions with non-specific or generic terms, such as ‘rash’, affecting the quality of referrals. Therefore, the authors reinforce the need to improve medical training in Dermatology, both in medical undergraduate and residency programs of other specialties.25

“Internal Medicine” presented the highest number of referrals to Dermatology, which corroborates the findings of other authors.5,8,10,12,26–28 The greater demand observed in this specialty may be related to its significant generalist and backup nature, as well as its high volume of assisted patients. As for the other medical specialties, the literature shows divergences in their demands, standing out in second place ‘Pediatrics’,12,26 as observed in this study; ‘Surgery’,1,10,29 ‘Hematology’,20 ‘Neurology’,5 and ‘Emergency Medicine’24 (Table 5).1,5,8,10,12,14,15,20,22–24,26–31 In addition, as reported by Galimberti et al.,10 clinical specialties presented more referrals than surgical ones. This can relate to the inpatient profile or even indicate a probable inattention to skin disorders from surgeons. This situation will require further studies for a better understanding.

Another relevant aspect consisted of the expressive amount of suspended or duplicated consultation referrals ‒ around 40% ‒ which may be related to communication difficulties among medical specialties teams, as well as the inadequacy of consultation referral flows to Dermatology. According to Alani et al.,1 dermatological consulting processes have their weaknesses, often presenting incomplete information and/or misdiagnoses, reinforcing the need of referral flows reorganization. In view of this, Prada-Garcia et al.32 observed that 74% of consulting referrals were requested again by the assistant teams within less than 48 hours of the first request, thus generating duplications.

Regarding the suspensions, these may be related to the lack of clinical criteria for hospital dermatological consultations, causing their suspension or even the patients’ discharge before the dermatologists’ evaluation. From this perspective, Mancusi et al.5 highlighted that 21% of dermatological referrals did not have severity criteria compatible with dermatological evaluation in hospital settings.

The dermatology team conducted 641 consultations over the 18-month period of study, with an annual average of 427 evaluations. This amount is in line with findings from other tertiary hospitals in Brazil,30 Spain,20 and Singapore.8 However, the result differs from hospital services in other countries, such as the United States10,21,27 and Peru,12 which may indicate a higher influence of intrinsic characteristics of hospitals than the macroeconomic and social conjuncture of these countries.

A considerable amount of the dermatological evaluations resulted in a single diagnosis (85.3%). Although in different proportions, this trend was also verified by Huang and Chong8 (52.4%), Fayne et al.24 (62.0%), Alani et al.1 (63.0%), and Samorano-Lima et al.30 (85.4%), evidencing the need for better understanding of that fact. ‘Dermatitis and eczema’ were the most frequent skin disease group, followed by infectious dermatoses ‒ represented by the groups ‘Infections of the skin and subcutaneous tissue’ and ‘Other infectious skin diseases’.

Despite the diversity of methods found in the literature, the authors noted comparable nosological profiles of hospital dermatoses in similar studies (Table 5),1,5,8,10,12,14,15,20,22–24,26–31 indicating a predominance of acute and inflammatory skin conditions. Considering that such clinical conditions are important factors of morbidity and mortality,6 reducing survival and increasing the length of hospital stay, Dermatology can substantially contribute to inpatient care.

Considering a similar investigation,33 conducted within the scope of Primary and Secondary Health Care in a capital city in southern Brazil, the authors identified a confluence among the profile of skin diseases in Primary Care and the tertiary hospitals of the present study. From this perspective, ‘Dermatitis and eczema’ and ‘Other infectious skin diseases’ stand out as the main dermatoses groups in both scenarios. However, they denote different frequencies: ‘Dermatitis and eczema’ 33.1% vs. 21.5%33 and ‘Other infectious skin diseases’ 21.8% vs. 25.6%.33

In face of the convergence among Primary and Tertiary Care profiles, a reasonable explanation may be the generalist nature of both scenarios, although they present particularities related to medical care practices and assisted population. Whereas in Primary Care33 ‘Atopic dermatitis’ (6.4%), ‘Other disorders of the skin and subcutaneous tissue’ (5.1%), and ‘Scabies’ (4.5%) appeared as the main dermatological diseases, our findings showed ‘Dermatitis due to substances taken internally’ (9.9%), ‘Unspecified dermatitis’ (6.6%), and ‘Herpesvirus infections’ (5.2%) as the most prevalent disorders among inpatients, conditions intrinsically associated with hospital care and states of immunosuppression.

Considering particular ICD dermatological diagnoses, the authors highlighted the preponderance of ‘Dermatitis related to substances taken internally’ (ICD L27) ‒ also denominated ‘drug eruptions’ or ‘cutaneous adverse drug reactions’, presenting high prevalence in most age groups, with peaks in ages ‘26‒45 years’ and ‘56–65 years’. Such findings are in accordance with the profile of hospital dermatoses in other institutions: Goztepe Research and Training Hospital in Turkey26 (10.9%); Jackson Memorial Hospital24 (9.9%), Mayo Clinic27 (12.9%) and Cleveland Clinic10 (13.0%) in the United States; University Hospital “Dr. Jose Eleuterio Gonzalez”28 (13%) in México; and Singapore General Hospital31 (12.3%) in Singapore.

During hospitalization, recurrent exposition to systemic medications ‒ especially analgesics, non-steroidal anti-inflammatories, and neuroleptics ‒ as well as debilitated patients’ conditions consist of significant risk factors for drug skin disorders.5,34 Thus, the risks of irrational prescriptions inwards need to be alerted to assistant medical teams.

Another relevant aspect refers to the predominance of infectious dermatoses, such as scabies and impetigo, and inflammatory skin disorders, such as seborrheic dermatitis and atopic dermatitis, among children and adolescents. These findings agreed with previous studies,16,32,35 which pointed out infectious and inflammatory dermatoses as the main skin conditions among inpatients under 18 years old. Skin fragility and immunological immaturity of patients in this age group may be likely explanations for these results.

As for the complementary investigation, converging with similar studies,10,23,24,26,29 skin biopsies were the most recommended exams, being performed in 21% of the consultations. This proportion, however, proved to be lower than the findings of other authors: Galimberti et al.10 (30.8%), Lorente-Lavirgen et al.20 (35.4%), Fernandes et al.29 (34.8%), Huang et al.8 (31.0%) and Fayne et al.24 (41.2%). This difference may be related to varying degrees of severity and/or complexity of skin disorders among the studies, or it may correspond to the clinical experience and clinical management practices of the services. Thus, the authors emphasize the concordance rate of 58.8% between clinical diagnoses and pathological reports, which differs from the rates of the Cleveland Clinic10 (71.9%).

The consulting team recommended mostly corticoids (27.1%), mainly in the topical form, reinforcing the inflammatory and acute character of the skin disorders. In most consultations, the Dermatology team did not recommend immediate therapeutic approaches (60.8%), in contrast to similar studies,10,24 which suggests that such cases were residual or resolving conditions, or could be followed up on an outpatient basis, not requiring interventions during hospitalization.

Regarding the follow-up recommendations, outpatient follow-up was recommended in 49.3% (316/641) of dermatological consultations, similar to the findings at the Jackson Memorial Hospital (55.0%),24 but higher than reported in the University Limerick Hospital1 (33.0%).