Introduction
The different scenarios that can be covered in a communication station are vast.
Common themes revolve around: conflict resolution; difficult referral/conversation and breaking bad news.
Other scenarios that have come up include obtaining consent; managing a patient with a needle stick; the CDU ward round; a major incident and departmental flow.
Pay attention to
- Body language – what messages are you sending to your patient and are they sending to you
- Silence is golden (but feels uncomfortable – count to 10 before speaking after breaking bad news)
- Let the patient speak
- Involve the patient/other specialty in decision making
- Don’t make promises you can’t keep
- Try to remain calm
Common Scenarios
Complaints/Angry patient or relatives
Preparation prior to discussion
I would ensure:
- Any immediate patient safety concerns are addressed.
- The department is safe (handed over to a colleague).
- Information gathering had occurred (eg, review of notes, ideally see patient yourself).
- Quiet, private location.
- Senior member of nursing staff present.
Introduction and acknowledgment of problem
“Hello, my name is Dr Smith, I am one of the Senior Doctors working in the Emergency Department today.”
“Can I just confirm your name and whose relative you are?”
“I have been told you have concerns you would like to discuss, shall we move to somewhere more private to do this?”
“Before we start, shall we sit down, and is there anything I can get you? Do you need any pain relief or a drink (situation dependent)?”
Problem
“Please can you tell me what you are concerned and unhappy about?”
Acknowledge concerns
“Thank you for informing me of this.”
“Let me just summarise what you have said so I can ensure I understand your concerns.”
Apologise
“I am really sorry that you/your relative feel(s) like this, and I want to do all I can to improve things going forward.“
Plan
“Firstly: I would like to:
ANGRY PATIENT: “listen to your history and examine you. We can decide on a plan and any investigations together.”
ANGRY RELATIVE: “go and see your relative and ensure they are now comfortable. I will then take a history and examine them and look at any results so we can make a plan together.“
“Does that sound reasonable to you?”
“Secondly:
“I want to try and reassure you that we take concerns very seriously and this incident/issue will be looked at formally. I will complete an incident form and ensure the Consultant/Matron are aware.”
“We always ensure we learn from any incident to try and ensure it doesn’t happen again. Usually this is by speaking to those directly involved and wider departmental awareness through teaching”
Closure
“For the time being have we managed to address your concerns?”
“Is there anything else you want to discuss?”
“If now or later you want to raise this further you can contact the Patient Advice Liaison Service, they can give you advice about how to make a formal complaint if you so wish. I can go any get you their contact details now if you would like.”
“Thank you for raising this issue with me.”
Complaints procedure
If there is an immediate concern you need to decide whether the complaint meets the SIRI (serious incident requiring investigation) threshold. If it doesn’t complaints are generally managed and escalated as follows:
- PALS if immediate resolution is possible/likely.
- Referral to the complaints team. This must be acknowledged within three days and a resolution meeting offered.
- A response* should be received within 30 days if not complex.
- Final approval of the response comes from the CEO.
- If the complainant is not satisfied, they can make a referral to the Parliamentary Health and Service Ombudsman.
*The response process involves an investigation, a draft response which is sent to the divisional nurse and allied HCP director, and a final response being sent to the CEO for them to approve.
Serious Events Framework
- Any untoward medical occurrence that results in death/life threat/prolonged stay
- Report on event within 2 days
- Initial review within 3 days
- Investigation & report with RCA (root cause analysis) within 60 days
- Commissioner review within 20 days of receipt of report
Duty of Candour
- A professional and statutory obligation to be open, honest and transparent with patients of their representatives when something goes wrong.
- Specifically this involves:
- Acknowledging
- Apologising
- Trying to put right is able
- Explain any short or long term consequences as a result of the incident
Example scenarios
- Long wait to be seen
- Missed fracture/diagnosis management
- Parents/caregivers or patient requesting CT head post minor head injury
Conflict Resolution
Preparation prior to discussion
I would ensure:
- Any immediate patient safety concerns were addressed.
- The department is safe (handed over to a colleague).
- Information gathering had occurred (eg, review of notes, ideally see patient yourself if a previous attempt to refer has not been successful).
- Quiet, private location.
- Senior member of nursing staff present.
Introduction and acknowledgment of problem
“Hello, my name is Dr Smith, I am one of the Senior Doctors working in the Emergency Department today.”
“Can I just confirm your name and whose relative you are?”
“I have been told you have concerns you would like to discuss, shall we move to somewhere more private to do this?”
“Before we start, shall we sit down, and is there anything I can get you? Do you need any pain relief or a drink (situation dependent)?”
Problem
“Please can you tell me what you are concerned and unhappy about?”
Acknowledge concerns
“Thank you for informing me of this.”
“Let me just summarise what you have said so I can ensure I understand your concerns.”
Apologise
“I am really sorry that you/your relative feel(s) like this, and I want to do all I can to improve things going forward.“
“Perhaps I can try and explain why I feel we should/should not be doing this.”
Plan
Consider the following where appropriate:
- Acknowledge concerns/frustrations
- Explain reasons of doing/not doing something
- Explore particular concerns
- Offer a second opinion
- If a condition: time frame, how to manage
- Safety net
- Try and agree plan
Closure
Just to summarise,
“Your concerns were…”
“We have discussed that…”
“Our plan is… including safety net and online resources”
“Do you feel I have addressed your concerns, or do you have any further questions?”
Example scenarios
- Request for antimicrobials
- Tick bite, requesting antibiotics
- Refusing tetanus
- Giving DVLA advice
Difficult Referral
Preparation prior to discussion
I would ensure:
- Any immediate patient safety concerns were addressed.
- The department is safe (handed over to a colleague).
- Information gathering had occurred (eg, review of notes, ideally see patient yourself if a previous attempt to refer has not been successful).
- Quiet, private location.
- Senior member of nursing staff present.
Introduction and reason for the call
“Hello, my name is Dr Smith, I am one of ED Registrars.”
“Are you the SpR/Consultant? Great, can I take your name and grade please?”
“I’m sorry to bother you, I hear you are really busy, but I need to discuss a case, are you free to talk?”
Outline Case
Use SBAR (Situation; Background; Assessment; Recommendations):
S: I have Mr Jones with…
B: The background is this…
A: Having just seen the patient I am concerned that…
R: Which is why I feel referral under your team is appropriate
Listen
- Listen to their concerns
Acknowledge and apologise
“Apologise: for anything brought up. For example “I’m sorry if you have experienced poor referrals previously”
Acknowledge their issues: For example “I appreciate you are busy…”
Restate concerns/that referral is needed and offer help
“BUT I am concerned about… I don’t think the patient is safe to discharge/admit to CDU etc, and I really would appreciate your input.“
“Is there anything I can do from our end which would be helpful to have prior to you seeing this patient? E.g. CT head, MRI“
Plan of action
Successful:
“Ok many thanks…”
“Do you have a rough time frame for when you may be able to make it down?”
Unsuccessful:
“I don’t think we are making progress here, what i’ll do is I will chat to my Consultant and ask them to ring either you or your Consultant directly, does that sound reasonable?”
Close
“Thank you for your time.“
I would then document the outcome and time of referral in notes.
Example scenarios
- ‘Social admission’
- Confusion about admission pathways (cardiology or medicine; orthopedics or spinal; etc)
Difficult Conversation
The approach will vary depending on the information given in the vignette. If the person has come to you directly or is clearly upset then your approach may be more direct than the one given below.
Preparation prior to discussion
I would ensure:
- Any immediate patient safety concerns were addressed
- Department is safe (handed over to a colleague)
- Information gathering (including review of clinical work done to date and any other patients seen during the time frame of concern)
- Another member of staff is present take notes (situation dependant)
Introduction and opening question
“Hi, I’m Dr Smith, one of the Senior Emergency Doctors on today.”
“I don’t think we’ve met properly before, what’s your name?”
“I was wondering if we could have a chat, shall we go to the office and have a cup of tea?”
“I just wanted to check if you are ok?”
Explore
Says NO – explore further
Says YES – “I just wanted to ask you because…”
- LISTEN
Probe for examples
INTOXICATION: one off? Do they think its a problem? Plans to address?
LIFE: money; unwell relatives; marriage upset
DIFFICULT COLLEAGUE/CASE
Acknowledge and support
“I’m sorry your feel like this/that this has happened”
“Is there anything I can do to help?“
Plan of action
SAFETY:
“My priority is to ensure you and our patients are safe (may include checking on patients seen previously)“
SUGGEST
“I think it may be best if you go home. What do you think?”
“Are you ok getting home or is there anyone who can come and get you?”
“Would it be ok if I gave you a ring later to make sure you are ok?”
“Don’t worry about the rest of your shifts for X number of days. We will cover them.”
STATE:
“I think it is important for your educational supervisor to be made aware of this. Do you feel able to approach them or would you like me to?”
“Other senior team members may need to be made aware, but we will protect your privacy as far as possible.”
ENCOURAGE:
“When you feel able I would suggest you write a reflection, and arrange to discuss this is your educational supervisor.”
Close
“Does all that sound reasonable?”
“Do you have any other questions or is there anything else I can do to help?”
Example scenarios
- Intoxicated colleague.
- Bullying (either being bullied or accused of).
- Failing/distressed trainee.
Breaking Bad News – New Diagnosis
Preparation prior to discussion
I would ensure I had:
- ensure the department is safe and handed over control of the department to a senior.
- bleep/phone off.
- read the patient’s notes.
- understood diagnosis, immediate and longer term management.
- member of nursing staff present to support patient privacy.
Introduction
“Hello my name is Dr Smith, I am one of the senior ED doctors working today.”
“Can you confirm for me your name and date of birth please?”
“Are you comfortable? Do you need any pain killers?”
Reason for conversation
“I have come to talk to you about what’s brought you into hospital and what we think is going on. Would that be ok with you?”
“Do you want someone else with you?”
Clarify history
“Can you briefly tell me what’s brought you to hospital?”
Current understanding
“Do you have any ideas about what is going on?”
Explain Diagnosis
“We think you have X.”
“Do you have much of an idea of what that is?” If no: brief summary
“We are treating X now and this will involve Y”
“It is something that can be managed really well with support.”
“This is a lot to take in, do you have anything in particular you want me to talk to you about?”
- Effect on life
- Resources
- Lifestyle changes (ETOH; smoking; drugs; weight; etc)
Close
“Do you understand what I have told you?”
“Anything you want me to clarify?”
“If being admitted, the X team will be able to go over things in more detail?”
“I have some written information and online resources to give to you.”
“Do you have any other questions?”
Paed/young adult: “do you want me to talk to your parents/carers?”
Example scenarios
- Anaphylaxis
- Type 1 Diabetes
- Atrial fibrillation
- Malignancy
Breaking Bad News – Death of a Patient
Preparation prior to discussion
I would ensure I had:
- ensure department is safe – handed over control of department to a senior.
- bleep/phone off.
- fully aware of the details of the patient’s case.
- member of nursing staff present to support them.
Introduction
“Hello my name is Dr Smith, I am one of the senior Emergency Doctors working today.”
“Can I just confirm your name; whose relative you are and your relationship to them? May I call you…”
“Is there any one else coming or anyone else you want with you?“
“Before we start can I offer you a drink or anything else?“
Confirm relative’s knowledge of events
“I’m really sorry you are here today. What is your understanding of the events that brought your loved one to hospital today?“
Break the news
“That is correct. Since she/he has been with us this is what has happened.”
“I am really sorry, but I have some dreadful news to tell you.”
Situation dependent:
“Mr X has died.”
“After discussion with (for example) the brain surgeons; given the extent of the injury, they do not feel this injury is survivable and your relative, NAME will die.”
SILENCE – count to 10
“Do you understand what I have said?”
Count to 10
“I can’t imagine how hard this news is to take in. Do you have an immediate questions for me?”
(offer to show any results or imaging that may be available)
Support/after care
“Is there anyone I can contact for you?”
“Would you like any religious representation?
“Would you like to see your Mr X?” If yes comment on what they will look like.
“I can’t imagine how awful all this is, but do you know if Mr X wanted to be considered for organ donation?“
Plan
“What I will do is give you some time now.”
“Our nurse X is here to stay with you. They will go over what will need to happen from now, but only when you are ready.”
“I am really so sorry for your loss. I am here if you think of any questions, no matter how small please let the nurse know and I’ll come back. My name is Trudie Smith and I will be here all evening.”
Example scenarios
- Adult or paediatric death
- Sudden explained death protocol
- Organ donation
CDU/Short Stay Ward Handover
In these stations, typically a junior will discuss a number of patients with you. Like the communication stations there is often a hidden agenda, often relating to further management, discharge information required or an educational component that you will need to elicit.
- Time passess really quickly in these stations. It is assessing your ability to make rapid yet safe decisions about patients in a supportive way.
Introduction
“Hi I’m Dr Smith the ED Doctor running CDU today.”
“I believe you have some patients to hand over to me?”
“What is your name and grade/previous experience?”
“Before we start I just want to make sure the rest of the department is safe and that there are no patient safety concerns.”
“Is there anything from an educational perspective you would like to discuss or do as an assessment?”
Cases
“So shall we start?”
“Is there anyone you are worried about or want to discuss first?”
Technique pointers:
- Allow uninterrupted handover of cases.
- Ask further questions as you feel indicated (eg. how the patient is now with results of any investigations).
- If you feel:
- further investigation or management is needed try and explore this with the junior to ascertain their understanding.
- a learning need has been highlighted explore this with the junior and offer resources to support learning.
“So, in summary we have:”
Summarise the ongoing plan for each patient, particularly the safety net instructions/resources for any patients going home.
Close
Thank the junior for their hard work
“We can discuss more formally as a Work Place Based Assessment if you would like?”
Example scenarios
Presenting complaint
Head injury
Older person with abdominal pain
Young female with abdominal pain
First fit
Hidden agenda
Meets CT brain criteria
Abdominal aneurysm not considered
Pregnancy status not considered
DVLA advice / safety netting not considered
Major Incident
Major Incident Concepts
Major incidents are thankfully a rare occurrence, however, they are a good exam fodder! Some of the key concepts have been summarised below.
Recommended reading are the NHS Clinical guidelines for major incidents and mass casualty events
Definition
- An incident(s) where location, number or severity of live casualties requires extraordinary resources.
Can be declared by any of the emergency services; Emergency Department clinician or nurse in charge, and NHS England
Examples
Big bang: incident – explosion
Rising tide: Developing infectious diseases – COVID
Cloud on horizon: CBRN/ war
Preplanned major event: Olympics
Categorisation
Standby
Declared
Stand down
Cancelled
Command Structure
Gold: Strategic; overall command, reports to NHS England
Silver:Tactical; controls hospital
Bronze: Operational control; resources
METHANE report
M – MI standby; declared; stand down; cancelled
E – Exact location
T – Type of incident
H – Hazards (present/potential)
A – Access to scene
N – Number and severity of casualties
E – Emergency services present
Triage
Prehospitally = SIEVE assess:
- Walking
- Breathing
- Respiratory rate
- Capillary refill
Hospital = SORT
- Adults: assess to calculate the revised trauma score, which gives you your priority score
- Blood Pressure
- GCS
- Respiratory Rate
- Paediatrics: ‘Jumpstart tool’:
- Breathing,
- Respiratory Rate,
- Pulse
- AVPU
Priority Score
| Priority | Revised Trauma Score | Time Frame |
|---|---|---|
| P1 (Major Trauma Centre) | <10 | Immediate resuscitation |
| P2 (Trauma Unit) | 11 | Urgent (not life threatening) |
| P3 (MIU/GP) | >12 | Minor/delayed treatment |
Major Incident Management
This station is often presented as a vignette with a pre-alert and you are expected to lay out your plan. Having an understanding of some of the basic terminology and concepts, as well as a structured approach will help you score well.
Writing a standard approach for this is difficult as there are multiple ways this station could be run. Below is hopefully a guide which will help you ensure you cover all the aspects that need to be considered”
Introduction (to who has given you the initial alert)
“Hello, thank you for giving me that information. I’m Dr Smith, one of the senior doctors, can I just confirm your name and your role as I haven’t met you before.”
Information
“Have you been given a METHANE report or other information?“
I would obtain the contact details of the senior on scene
Instigate Major Incident Plan
Confirm
Ensure not a hoax – call ambulance control to confirm.
Inform
Consultant in charge (if not you) and the nurse in change (NIC)
Silver command (site) ascertain whether declared or not
Switchboard (via Emergency number) – MI standby/declared call through switchboard
“I am the senior doctor in the Emergency Department. Please can you declare a major incident/major incident standby.”
Brief Team with Major Incident Plan
Ask NIC to gather Major Incident plan and box with designated phone.
Tannoy for senior clinicians and nursing staff to staff room for brief (providing it is safe to do so).
Brief the team
“We are on MI standby/declared/stand down.“
“I’m Dr Smith, one of the seniors today and I will be Bronze Command. I am clinically hands off and will be in the control room with the Nurse in Charge. Our contact number is…”
“Please can the rest of the team introduce themselves by name, role and grade.”
“This is the METHANE report we have received…”
“I will now allocate role. Please collect your tabard; follow your action card, and ensure appropriate PPE.”
“Once the ED is cleared we will have a hot debrief.”
“I now need to consider the following areas: staff; environment; documentation”
Staff
I need to:
Allocate teams
A senior clinician and senior nurse to act as team leaders to oversea each of the following areas:
- triage
- minors
- majors
- resus
- Aim for 1 trauma team per patient
Call out cascade via switchboard
- Do not call in everyone at once in case the incident is ongoing and you will need staff to support the department when the incident is complete.
Police and porters
Security for lock down (single point of entry / exit) and crowd control
Media
Environment
Triage (Sort – Revised Trauma Score: BP; GCS; RR = P1; 2; 3 – 3s ideally not enter ED be redirected).
Tent if decontamination needed.
Assess and clear waiting room and minors.
Assess and arrange safe transfer for majors/resus patients.
Reassign ED as per plan.
Survivor centre – reunite; support; psychosocial first aid.
Mortuary overflow
Documentation
Give Major Incident documentation and designated MI hospital numbers as soon as triaged.
Patient flow documentation.
Do you have any questions?
Other Scenarios
Needlestick
Typically this station involves a healthcare worker, however, it may also be a member of the public. Useful information on this topic can be found at RCEM learning and also on the BASHH website.
Introduction
“Hello, I’m Dr Smith one of the senior Emergency Department Doctors working in the ED today.”
“Can I confirm your name and date of birth please?
Problem
“Why have you come to the Emergency Department today? How can I help?”
History
Injury
- Time
- Type of needle (hollow vs solid)
- Procedure being done
- Gloves
- First aid
Recipient
- Immunised against Hepatitis B?
- Knowledge of antibody status?
Donor
- Known to have a blood borne virus
- Are they in a high risk group?
Management
Education on risks:
- Hep B – 1:3
- Hep C – 1:30
- HIV – 1:300
Donor:
- Consent for testing (not to be done by recipient)
Recipient:
- Blood for serum save (Hepatitis B surface antigen, HIV and hepatitis C antibody)
- Hep B: not immunised/not immune – discuss with genitourinary medicine/infectious disease
- No PEP if: low risk or known HIV but undetectable viral load
- Follow up with occupational health as per local guidelines
- Barrier contraception, no blood donation until clear at 6 months
- Incident form
- If very upset: not to continue with the shift; offer to explain to their senior.
If patient fees strongly regarding PEP, state you would contact the GUM/ID Consultant for their advice.
Close
“Do you have any other questions you want to ask?”
“Are you clear with the plan?”
Departmental Overcrowding/Queues
This is an easily testable scenario and suits a virtual platform well, however, it is one that candidates often haven’t prepared for.
The RCEM document ‘Tackling Emergency Department Crowding’ is a useful document to review. One approach taken by a previous candidate is using the mnemonic ‘PEWS BLIPS’ to act as a reminder of each of the important areas to consider.
Patient Safety
Ascertain whether any immediate patient safety concerns. The nurse in charge (NIC) is often best person to ask.
If yes: allocate a senior to see immediately.
Escalate to Site Team
Call site (silver command) and ask them to call back and update you about hospital wide situation.
State an incident form should be completed.
Walk around with Nurse in Charge
Identify pressure points or physical space to expand into (e.g. CDU).
Skill Mix
Are people currently working in their areas of strengths?
Change roles to help achieve priorities identified on the board round.
Consider whether staff can be pulled from other areas in the hospital to support.
Board Round with Nurse in Charge and Site Team
PRIORITIES, use team to:
- Clear CDU as able.
- Clarifiy plans on patient being seen.
- Direct admit to specialities – if patient has a clear destination and is clinically stable.
- Identify those likely to go home – ideally cohort in one place and assign senior.
Long stay patients (awaiting a bed)
Assign a Doctor-Nursing team to:
- Perform a safety round every 2-4 hours.
- Ensure all critical medications prescribed: antibiotics; diabetic; epilepsy
- Investigations reviewed and acted on if needed.
- Refreshments.
Investigations that will help flow
- Early CT heads for anticoagulated head injuries.
- Hip x rays for patients with likely neck of femur fractures.
Patients
- Make sure all patients who need it have pain relief.
- Apologise for waits.
- Make an announcement about the current situation so people are aware.
- Offer refreshments.
Staff
- Confirm they are aware of their roles.
- Ensure they all take their breaks fully.
- Support ambulance personnel who may be in the department.
Obtaining Consent
These stations are focused around ensuring you fulfillful the seven principles of decision making and consent as laid out by the General Medical Council.
To demonstrate this any procedure or treatment you would recommend to a patient could be used, often this is consent for procedural sedation.
Introduction
“Hello, my name is Dr Smith, I am one of the Senior Emergency Doctors working in the Emergency Department today
“Can you confirm your name and date of birth please?”
“How is your pain currently? Do you need more pain relief?”
Check understanding
“Whats your understanding of what has happened to your shoulder?”
“Have you seen your x-ray and been told the results?”
“This is your x-ray, this is the shoulder joint and it shows it is out of joint currently.”
Management
“We need to get the shoulder back into joint for you.”
“The options are trying to put it back in joint with gas and air ‘laughing gas’ or giving you some medication to make you sleepy and relax the muscles in order to help us to get the shoulder back in.”
“Have you any immediate thoughts about what you would like?”
Appropriate indication
For procedural sedation you need to ensure you consider:
- The anaesthetic assessment: LEMON; ASA; fasting status
- Safety of the rest of the Emergency Department.
Informed consent sedation
“In order for you make an informed choice about making you sleepy I need to talk to you about pros and cons…”
PROS: “It will help make the procedure less painful and we are more likely to be successful.”
CONS: “like with all procedures there are risks.
Sedation: the drug I would use would be propofol. These are the possible complications I need to make you aware of and how I will try to reduce them:
- Pain 70%
- Low blood pressure 1.5% (fluids)
- Vomit 1.5% (anti sickness)
- Low oxygen levels (4%)
- “In a very low number of cases we may need to help you with your breathing for a short while (0.6%). The procedure is done in a highly monitored area equipped to deal with these problems.”
Manipulation:
- Unable to reduce; may need to go to theatre.
- May cause a fracture.
Understanding
“Do you have any questions?”
“I would like to leave you for a while to give you time to think about what we have discussed… What have you decided?”
“Let’s complete the consent form and try to get you better”