Chapter 4 – Communication Stations

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.

“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)?”

“Please can you tell me what you are concerned and unhappy about?”

“Thank you for informing me of this.”

“Let me just summarise what you have said so I can ensure I understand your concerns.”

“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.“

“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”

“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.”

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.

“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)?”

“Please can you tell me what you are concerned and unhappy about?”

“Thank you for informing me of this.”

“Let me just summarise what you have said so I can ensure I understand your concerns.”

“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.”

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

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?”

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.

“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?”

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

“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…”

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?”

“Thank you for your time.“

I would then document the outcome and time of referral in notes.

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)

“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?”

Says NO – explore further

Says YES – “I just wanted to ask you because…”

INTOXICATION: one off? Do they think its a problem? Plans to address?

LIFE: money; unwell relatives; marriage upset 

DIFFICULT COLLEAGUE/CASE

“I’m sorry your feel like this/that this has happened”

“Is there anything I can do to help?“

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.”

“Does all that sound reasonable?”

“Do you have any other questions or is there anything else I can do to help?”

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.

“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?”

“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?”

“Can you briefly tell me what’s brought you to hospital?”

“Do you have any ideas about what is going on?”

“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)

“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?”

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.

“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?“

“I’m really sorry you are here today. What is your understanding of the events that brought your loved one to hospital today?“

“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)

“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?“

“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.”

“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?”

“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.

Thank the junior for their hard work

“We can discuss more formally as a Work Place Based Assessment if you would like?”

Can be declared by any of the emergency services; Emergency Department clinician or nurse in charge, and NHS England

Big bang: incident – explosion

Rising tide: Developing infectious diseases – COVID

Cloud on horizon: CBRN/ war

Preplanned major event: Olympics 

Standby

Declared

Stand down

Cancelled

Gold: Strategic; overall command, reports to NHS England

Silver:Tactical; controls hospital

Bronze: Operational control; resources

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

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

“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.”

“Have you been given a METHANE report or other information?“

I would obtain the contact details of the senior on scene

“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?

“Why have you come to the Emergency Department today? How can I help?”

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 patient fees strongly regarding PEP, state you would contact the GUM/ID Consultant for their advice.

“Do you have any other questions you want to ask?”

“Are you clear with the plan?”

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.

Call site (silver command) and ask them to call back and update you about hospital wide situation.

State an incident form should be completed.

Identify pressure points or physical space to expand into (e.g. CDU).

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.

PRIORITIES, use team to:

1. Clear CDU as able.
2. Clarifiy plans on patient being seen.
3. Direct admit to specialities – if patient has a clear destination and is clinically stable.
4. Identify those likely to go home – ideally cohort in one place and assign senior. 

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.

• Early CT heads for anticoagulated head injuries.
• Hip x rays for patients with likely neck of femur fractures.

• 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.

• Confirm they are aware of their roles.
• Ensure they all take their breaks fully.
• Support ambulance personnel who may be in the department.

“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?”

“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.”

“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?”

For procedural sedation you need to ensure you consider:

• The anaesthetic assessment: LEMON; ASA; fasting status
• Safety of the rest of the Emergency Department.

“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.

“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”