Making a referral with Iain Beardsell @ St.Emlyn’s

One of the many highlights of SMACC2013 was meeting like-minded colleagues who are passionate about education and social media. Iain Beardsell is a UK emergency physician based in Southampton. Iain has put together the SEMEP website with a series of videos and links aimed at helping junior docs get started in EM. These have been featured on Life in the Fast Lane already, but there is no harm in advertising them again. We use them in Virchester – because they are really good – so check them out by following the links. You can see Iain in action together with his excellent colleagues including the College president (Mike Clancy) himself!

In the spirit of FOAM Iain has put together a quick blog post for St.Emlyn’s on how to make a good referral, a major concern for many docs when they start in EM.

Take it away Iain…..

 

Making a referral

Making referrals to inpatient teams is one of the most challenging aspects of working in the Emergency Department. Every call you make generates work for your colleagues, who may already be dealing with multiple calls and patients and may be in theatre or the out patient clinic. Without proper preparation instead of being a simple one way delivery of information it can turn into an impromptu viva examination.

So……

1, Don’t ask in patient specialities for “advice”. Immediately they will think that by giving advice they can avoid the referral and thereby avoid seeing the patient.
2, Don’t let yourself be interupted. If you have prepared a concise referral with only the pertinent details it should keep the attention and not take long.
3, Do not accept being fobbed off with advice to do further tests or keep the patient in the ED. The decision to admit is generally a clinical one and testing rarely makes a difference to whether the patient comes in or goes home.

Referral – how to make it easier
Before calling it is vital that you are clear on the purposes of your call – which will almost always be a referral for admission. Remember, if you need advice that is what your Consultant and Registrar colleagues in the ED are for. When starting out it is worth just running over the reason for your referral so you can anticipate any questions and hone down the content to just the things the person to whom you are referring needs to know. It is vital that for your own sanity and the patients well being the referral does not become a viva on your clinical knowledge, so prepare in advance.

 

The SBAR Way
At Southampton use the SBAR mnemonic to frame our referrals. This gives a format to these conversations and outlines the content of the referral.

 

  • S- Situation – Identify yourself, your patient and why you are calling- “Hi, This is Iain Beardsell one of the ED Doctors and I want to refer a 39 year called Jane Smith who I believe has appendicitis.”
  • B – Background – Give some more details about the patient- “She has had 24 hours of worsening right illiac fossa pain, with nausea, anorexia and three episodes of vomiting. She is previously fit and well and has no other relevant history.”
  • A – Assessment – Outline your assessment- “On examination she is tender in the right illiac fossa. Her urine dipstick is negative and her blood tests are awaited.”
  • R – Recommendations – Say what you believe needs to happen next- “I would be most grateful if you could review her and assess whether she needs further observation or a operation. I have requested a bed on the surgical ward.”

Tips on referring

  • 1, Never, ever lie or try to “sell” a patient. If you feel you have to do this ask yourself does the patient really need to be admitted or is there something else you could be doing in the ED? Also, word soon gets round if you are not telling the truth about patients and that important trust between you and the inpatient team is lost.
  • 2, Practice your referral in your head – Does it make sense? Is the reasoning clear? Are there any questions you might be asked that you cannot answer?
  • 3, Introduce yourself with your name, not just your designation and try to refer to the inpatient specialist by their name. By personalising the process it is much harder for someone to be rude to you and dismiss your request.
  • 4, You are referring the patient. Very, very rarely will you be “asking for advice”. Your expected outcome is admission not further work up in the ED/CDU.
  • 5, Try to get to know the inpatient teams (see 2 above) and show an interest in your patient’s outcome. Try to call them later in the shift to find out how your patient did – not only does they help your learning, but shows the in patient specialist that you were interested in your patient having the best and most appropriate care, not just how you could shift them from the ED and forget about them
  • 6, Remember that colleagues can be very busy. You may have just interrupted their lunch – no wonder they can get grumpy. Try and be understanding whilst being assertive.
  • 7, Finish your referral with your voice going down in pitch – suggesting the end of the conversation, rather than rising – suggesting you are asking a question and opening up an unwanted viva opportunity.
  • 8, Show “Grace Under Pressure”. Never, ever get into an argument about a patient – as soon as you raise your voice you have lost the moral high ground. If you are having real trouble inform the inpatient specialist (politely) that you are going to talk to your Consultant/Registrar to confirm the referral was appropriate and that you will call them back

Finally, it’s probably fair to say that making referrals is a skill. Just like all things in medicine it is something that you will need to practice and reflect on.

 

[author] [author_image timthumb=’on’]http://profile.ak.fbcdn.net/hprofile-ak-snc6/274698_682755334_1671886285_q.jpg[/author_image] [author_info]Iain Beardsell (Southampton)[/author_info] [/author]

10 Comments

  1. Andy Buck

    Good post Ian. I think one of the quintessential skills of working in Emergency is “selling ice to Eskimos”. ie Giving work to people who already have too much work and don’t want or need any more. One of my best friends runs a very successful pub, and one of his business mantras is “make it as easy as possible for people to say “yes” to you. How likely are you to buy another beer from a publican who is pushy, rude, argumentative, or terse? So why be like this if you’re making a referral? I live by the mantra “you catch more flies with honey, but very rarely you have to squash the really annoying ones with a rolled up newspaper”.

    One of my mentors also reinforced the point of staying objective and avoiding subjective arguments. Keeping this in mind keeps me stay focused on the facts of the case and avoids one being dragged into subjective arguments.

    I often do however call inpatient teams for advice, as sometimes it’s not clear whether the patient needs admission, and opening the call with this often takes the edge off, as the recipient immediately relaxes knowing that you are not just calling to dump another case on them. The ensuing discussion often draws out facts that lead the recipient of the call to agree that indeed they do need to come and see the patient. Allowing them to come to this conclusion (with your guidance) is an effective Jedi mind-control trick that I find useful on occasions.

    Reply
  2. Nadim Lalani (@ERmentor)

    thanks for this post. I have added a link to it on my blog post of Kessler’s 5-C’s.
    Nadim

    Reply
  3. John Mackenzie

    Thanks good stuff.

    I hope that some day my patience will be as bountiful as my patients and I can use more carrot ( or honey Andy) than stick.
    We are trying to encourage referrals to consultants only in my Australian metro hospital and I understand this likely to be a long way away in the UK. The consultants have less time and occasionally less rectal mucosa covering their ears so the admission is more rapidly facilitated. We have a small but significant cohort where for an admission you present the case and ask for advice as you “want to send home”, they immediately seize the high ground and suggest admission, and vice versa.
    Direct to registrar calls does remain a significant portion of our calls.
    The difficult issue irrespective of who you call is the professional conversation is tainted with power and that power is always the same direction. In a SA hospital where I locumed for some time the system was to book the admission administratively prior to any call.
    I am calling to let you knwo about an admission (it was mandatory to do it this way). The “power” is now totally in the hands of the ED, it mandates one way referral and encourages rapid review in the ED if they really believe it is not for them.

    This didn’t appear to lead to increased risk or error.

    Reply
    1. Ash

      I always rang the consultant in the UK, who ofcourse were friends as well as colleagues when I needed advice. Never ring registrars for advice, was my motto in the UK and even now in WA.

      Quite often I will speak to a consultant when faced with a more complicated admission [not necessarily unstable] and once that discussion leads to “yes admit”, I then confirm that point with the registrar who I am referring to. I do though wait till the point in the referral very calmly when they tell me “he/she doesn’t need to be admitted”, before revealing that admission has been agreed with the consultant.

      I also tend to try not to argue with registrars who refuse a referral. I call up the consultant and it is easier for the consultant to educate his/her own registrar once I have woken him/her up.

      Reply
  4. TChan (@TChanMD)

    There are a few more evidence-based models to use too! I don’t mind SBAR, but I find it misses somethings.

    The problem is there is a nomenclature difference between North America and the UK. In the US they are calling these ‘consultation requests’ and in the UK they call them referrals. In Canada, of course, we call them both.

    I think that Nadim’s right on the head, the leading ED consultation model is Chad Kessler’s 5C’s. It has been validated prospectively (http://www.ncbi.nlm.nih.gov/pubmed/22905961), Chad and I are friends, and published an article in Academic Medicine (http://journals.lww.com/academicmedicine/Abstract/2013/06000/I_m_Clear,_You_re_Clear,_We_re_All_Clear__.12.aspx) on this a few months after this blog post was created.

    There’s also our little Canadian teaching mnemonic PIQUED that we derived (http://www.ncbi.nlm.nih.gov/pubmed/23283122), but have yet to validate:
    P – Preparation
    I – Identification of Parties (You, consulting MD, patient)
    Q – Questions (Clinical Question)
    U – Urgency
    E – Educational Modifications
    D – Debriefing / Discussion after consult is completed.

    And most recently, we hosted this as a MEdICS case at ALiEM and got a lot of useful tidbits from the masses. (http://academiclifeinem.com/medic-the-case-of-the-difficult-consult-expert-and-community-response/)

    Love this topic, obviously, and glad that it’s sort of a universal need! Hopefully you folks will find some of this stuff useful! As a clinician, but also as a researcher in this area, I’m very excited to see posts like this. Always!

    Reply
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