Referring Patients from the Emergency Department

Rob Rogers featured a great presentation by Chad Kessler on EMRAP: Educator’s Edition on ‘how to communicate with consultants’ — in other words (for those not in North America), how to make a referral to an admitting team from the emergency department. This is a crucial part of the job of an emergency doctor, yet formal training on this skill is almost non-existent.

A summary of the key points of the talk follows, but be sure to check out the talk itself for role-played examples and an enthusiastic and detailed discussion of the topic. It is particularly useful for students, interns or other doctors just starting out in the emergency department.

First, remember the ‘Amal Mattu rule’:

Be Nice

Don’t get angry. Don’t get personal. Conflict causes consultations to go down hill – no one wins.

Secondly, remember the ‘Platinum rule’:

Treat others as they would like to be treated.

Profile the people you’re talking to, and be adaptable to their needs – but remember not everyone fits the stereotypes:

• Do they just want the ‘bare bones’ so they can get down to business?
  (Surgical stereotype – direct and guarded)
• Do they want to mull over all the data?
  (Medical stereotype – indirect and guarded)
• Are they extroverted socializers with short-attention spans who want the facts?(Emergency stereotype – direct and open)
• Are they ‘relaters’ who want to know all about the emotional and social circumstances?
  (Psychiatrist stereotype – indirect and open)

Thirdly, remember to:

Be soft on the people, but hard on the issues.

Be understanding of the consultant’s problems and differing opinions, but always focus the discussion on what is best for the patient.

Never feel bad about making a referral: you’re just doing what is best for the patient, and it’s the consultant’s job to respond.

Be aware of the drawbacks of different approaches, particularly in terms of how they affect your relationship with the consultant and the task at hand:

• Forcing
  “You will come to the ED now”. This destroys relationships.
• Smoothing
  “OK, sorry, I’ll try calling the other consultant”. Preserves the relationship (kind of) but does nothing for the task.
• Avoiding
  “Can you just come down?” – then hang up. Kills the task and the relationship.
• Compromise
  “How about we wait an hour, then you can see the patient?” Helps preserve the relationship to some extent, and goes some way to achieving the task but is not usually the ideal result.
• Confronting
  A problem-solving approach that benefits all. “OK, you send your registrar down to get things moving and we’ll have all the equipment ready for when you’re able to come down in half an hour.” Preserves relationships and achieves the task at hand. This is the ideal approach, but is not always possible…

Treat the referring process like ordering at a drive-through:

• “Check out the menu”
  Collect your information and get yourself prepared first.
• “Talk to everyone in the car to find out what everyone wants”
  Check with other emergency department staff (colleagues, supervisors, nurses, etc.) to gather more information.
• “Get your money ready”
  Sit in front of the computer with the patient’s results on screen, etc.
• “Place your order”
  Say exactly what you want or what you think needs to be done — be specific, you can’t ask for the ‘Chef’s special’!

Finally, the referral process can be summarized by the “5 C’s approach“:

• Contact
  Identify yourself, your role, where you are calling from and why you are calling. Confirm who you are speaking with.
• Communicate
  Give a concise story consisting of relevant positives and negatives appropriate to the consultant’s needs. Be pleasant and respectful, address the consultant by name, listen and do not interrupt.
• Core question
  Explicitly state what you require the consultant to do. “I think this patient has appendicitis. Can you come down and decide if you think the patient needs to have an appendicectomy?”
• Collaborate
  Work together to facilitate what is best for the patient. “OK, I’ll organize the CT while you finish up in outpatients.”
• Closing the loop
  Ensure that you’re both on the same page –– summarize and confirm the plan with the consultant, including the time when the patient will be reviewed.

Finally finally, medical students and interns should also check out how to present cases in the Emergency Department before they start work. Good luck!

References and Links

• Kessler C, Kutka BM, Badillo C. Consultation in the emergency department: a qualitative analysis and review. J Emerg Med. 2012 Jun;42(6):704-11.
• Westafer L. Sweating Bullets and Killing ’em With Kindness – Calling a Consult. The Short Coat