Picture the scene…
You have seen a patient who needs further care under the surgical team and you need to make a referral to the Surgical Registrar…
To learn some hints and tips to take the stress out of referring patients for ongoing care in the Emergency Department
Task 1 – Read
Read this blog post from RCEM Learning.
Task 3 – Discuss
This part of the teaching session should be lead by an experienced clinician. The priority in this task is to put together succint referrals and practice delivering them to a colleague.
During the discussion you may want to talk about particular quirks in your hospital system that are particulary relevant.
Case 1 – Referring a patient with chest pain
Read the following history and examination…
Name – Phillipa Bucket DOB 25th May 1965
- PC, Chest pain
- HPC, Felt chest pain at 11am today. Severe and radiating down the right arm. Made her felt very short of breath.
- Smokes 20 a day.
- Pain ongoing
- No previous cardiac history
- Appendicectomy aged 19. Hypothyroid.
- On amlodipine and metformin.
- Mother and father still alive – no cardiac history.
- O/E – Comfortable, apyrexial
- CVS, Pulse 70 reg, BP 140/75, HS I & II & nil ECG Lateral ST depression
- Resp – Chest clear
- Impression, Chest pain ?cause ?ACS
- Plan – Refer Cardiology
Using the information given write a referal to the Cardiology Team using a SBAR format
Situation (James Bond Opening)
“Hi, Thanks for calling back. I’m Iain, one of the ED doctors. Please may I refer to you a 55 year old female who has presented to the ED with chest pain who I believe may have acute coronary syndrome
The pain came on suddenly at 11am today and hasn’t resolved. It radiated down her right arm and made her feel short of breath. She smokes 20 a day and is on antihypertensive medication, but has no family history, diabetes or high cholesterol. On examination her vital signs are normal, but she has lateral ST depression on her ECG. Her blood tests including a first troponin are awaited.
I am concerned that she has cardiac sounding chest pain, with some risk factors and an abnormal ECG.
I have confirmed that she has had 300mg of aspirin and have prescribed fondaparinux. She is on a cardiac monitor and I am treating her pain with intravenous morphine and I would be grateful if you could review her as I think she needs to be admitted to the Coronary Care Unit for further care.
Case 2 – Referring a patient with abdominal pain
Read the following history and examination…
Name – Victoria Pollard DOB 25th May 1985
- PC, Abdominal pain
- HPC, Noticed gradual onset “grumbling” abdominal pain a few days ago, which has become more severe today.
- Not sexually active
- LMP five days ago
- Not hungry. Not eaten. Vomited three times.
- Lives with her parents
- O/E – Comfortable, Temp-37.5
- Abdo: Pain in RLQ.
- CVS: Pulse 90 reg, BP 120/75
- Resp: Chest clear
- Impression, Appendicitis.
- Plan: NBM; iv fluids; refer surgery; blood tests awaited
Using the information given write a referal to the Surgery Team using a SBAR format
“Hi, Thanks for calling back. I’m Iain, one of the ED doctors. Please may I refer to you a 25 year old female who has presented to the ED with abdominal pain, anorexia and three vomits, who I belive has appendicitis.
She is usually fit and well, but three days ago started having diffuse abdominal pain. On examination she is tender in the right illiac fossa.
I believe she has appendicitis.
I’d be really grateful if you could see her on the surgical unit. I have made her nil by mouth and started her on intravenous fluids and given her intravenous paracetamol.
Task 4 – Summary
In this session we have learned about how to refer patients to speciality colleagues. Remember these top tips:
- 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.
Task 5 – Reflect
In order to embed today’s learning further, reflect on what you have learnt and record in your portfolio whether it has had any impact (or is expected to have any impact) on your performance and practice.
Will this change how you approach your next referral?
Discuss this session with your colleagues – were there people who missed it who you can share the highlights with? Can you practice referrals together?
If you’re not sure what I mean by a James Bond Opening, watch this……