In the fast-paced environment of the emergency department (ED), effective communication is paramount, especially when referring patients to inpatient teams. This process, I think, is often overlooked in medical training, but it’s crucial for ensuring the best patient outcomes and fostering professional relationships. Poor communication can lead to misunderstandings, delayed treatments, and even compromised patient safety. It can also create real anxiety. In this episode of the St. Emlyn’s podcast, we’ll look at the nuances of making clinical referrals using a structured approach known as the SBAR (Situation, Background, Assessment, Recommendation) format. We’ll explore the importance of clear and concise communication, the use of engaging openings, and strategies for handling challenging conversations.
Listening Time – 17:54
The Importance of Clear Communication in Referrals
Every day, ED physicians make numerous referrals, each with the potential to significantly impact patient care. These referrals are not just routine tasks; they are critical touchpoints that determine the continuity and quality of care a patient receives. When done correctly, they ensure that the receiving team understands the patient’s needs and urgency, allowing for timely and appropriate intervention. Moreover, well-handled referrals can enhance the referring physician’s reputation, fostering respect and collaboration across departments. In contrast, poor referrals can lead to delays, confusion, and a breakdown in interdepartmental relationships.
The James Bond Opening: Capturing Attention
In the world of cinema, James Bond movies are renowned for their captivating opening scenes—high-energy, dramatic, and designed to hook the audience immediately. This concept can be translated into medical referrals. The “James Bond opening” involves starting the conversation with the most critical piece of information, ensuring that the receiver’s attention is immediately focused on the key issue. For instance, instead of a vague statement like, “I have a patient with some abdominal pain,” you can lead with, “I have a 25-year-old male presenting with symptoms strongly suggestive of appendicitis.” This engages the person you are talking to, and establishes early on that what you are about to say is relevant to them.
The SBAR Framework: Structuring Effective Referrals
The SBAR format is a standardized method of communication that structures information in a clear, concise manner, ensuring that no critical details are overlooked. Let’s break down each component:
Situation
This initial segment focuses on the immediate clinical scenario. It’s about presenting the essence of the issue in one or two sentences. For example, “Please may I refer a 65-year-old female patient presenting with acute shortness of breath” This succinct statement sets the stage, providing a snapshot of the patient’s current condition and highlighting the urgency. Utilising the idea of the James Bond opening, I would go one step further “”We have a 65-year-old female patient presenting with acute shortness of breath, requiring supplemental oxygen, who I believe has an infective exacerbation of COPD”.
Background
The background provides the context necessary to understand the situation. It includes relevant medical history, recent events, and any treatments administered. For instance, “The patient has a history of chronic obstructive pulmonary disease (COPD) and hypertension. She was brought in after experiencing a sudden onset of symptoms while at rest. Vital signs show tachycardia and hypotension.” This background information helps the receiving team grasp the patient’s baseline status and recent changes, which are crucial for accurate diagnosis and treatment planning.
Assessment
In this section, the referring physician provides their clinical judgment. It’s an opportunity to convey your evaluation and the reasoning behind the referral. For example, “Given the presentation and her medical history, I suspect a possible pulmonary embolism or acute coronary syndrome.” This assessment not only indicates the likely diagnoses but also shows that the referral is based on a thorough clinical evaluation, enhancing the credibility of the referral.
Recommendation
The final part of SBAR specifies what action is needed. Clarity is crucial here, as it directs the receiving team’s next steps. For instance, “I think the patient needs urgent CT pulmonary angiography and admission for further assessment, observation and treatment”. This recommendation not only outlines the immediate needs but also provides a status update, helping the receiving team prioritise and plan their response.
Enhancing the Referral Process: Practical Tips
Introducing Yourself Clearly
A simple yet often neglected step is starting the conversation with a clear introduction. This sets a professional tone and builds rapport. For example, “Hi, this is Iain, one of the doctors from the ED. I’m calling about a patient who requires urgent surgical consultation.” Such an introduction immediately clarifies who is speaking and the purpose of the call. If the person on the other end does not introduce themselves by name, it’s polite and useful to ask, “I’m sorry, I did;t catch your name” This not only personalises the interaction but also facilitates future communications. After all as humans we are social creatures, looking for connection. You wouldn’t walk up to someone in a bar and introduce yourself as “Hi, Emergency Doctor. Nice to meet you” (at least I hope you wouldn’t!)
Predicting and Preparing for Questions
Anticipating questions from the receiving team can streamline the referral process. Before making the call, consider what information they might need and have it ready. Put yourself in their position. For example, in the case of a suspected appendicitis, be prepared to discuss symptoms, physical exam findings, laboratory results, and any imaging studies performed. Being prepared shows professionalism and thoroughness, and it can prevent delays caused by missing information. Remember also that if you are asked questions, this may not be the receiver questioning your competence or whether they will even #’accept’ the patient, but simply trying to work out the urgency of when they need to see the patient.
Using the Illusion of Choice
A subtle technique to manage the referral conversation is offering the receiving team a choice, even when the options lead to the same outcome. For instance, you might say, “Would you prefer to see the patient in the ED, or should we transfer them directly to your ward?” This technique, known as the illusion of choice, gives the receiving team a sense of control and involvement in the decision-making process, fostering cooperation and reducing resistance.
Handling Difficult Conversations
Not all referrals proceed smoothly. Sometimes, the receiving team may be uncooperative or resistant. Here’s how to navigate these challenging situations:
Staying Calm and Professional
In cases where the conversation becomes tense, it’s crucial to remain calm and professional. Avoid raising your voice or becoming defensive. Instead, focus on patient care and maintain a respectful tone. If the situation escalates, a useful tactic is to suggest a pause: “It seems we need a moment to reassess. I’ll consult with my senior and get back to you shortly.” This approach not only de-escalates the situation but also buys time to reassess the case and consult with more experienced colleagues.
Seeking Support from Senior Staff
If you encounter significant resistance or disagreement, it’s advisable to involve senior staff. Senior doctors or consultants can provide additional authority and perspective, helping to resolve disputes and ensuring that the patient receives appropriate care. For instance, you might say, “Let me confer with my consultant, and I’ll call you back.”
Empathising with the Receiving Team
Understanding the pressures and constraints faced by the receiving team can help ease tensions. Acknowledge their challenges, whether it’s a high workload, staffing shortages, or other stressors. Some of these may not even be work-related – they might have been up all night with a newborn baby – For example, “You sound very busy; is there anything I can do to help?” Such empathy can foster a more collaborative and supportive atmosphere, making it easier to reach a consensus.
Practicing and Perfecting Referral Skills
Like any clinical skill, making effective referrals requires practice. It’s not just about what you say, but how you say it. The tone, clarity, and confidence in your voice can significantly impact how the referral is received. Practising with colleagues, role-playing different scenarios, and seeking feedback can help refine these skills. Additionally, reflecting on past referral experiences—both successful and challenging—can provide valuable insights for improvement.
Conclusion: The Value of Effective Referrals
Effective communication in the form of well-structured referrals is a critical component of patient care in emergency medicine. By employing the SBAR framework, initiating with a compelling “James Bond opening,” and preparing for potential questions, physicians can enhance the clarity and efficiency of their referrals. Moreover, handling difficult conversations with professionalism and empathy ensures that even challenging situations are managed effectively.
The ability to make clear, concise, and effective referrals improves patient outcomes, strengthens interdepartmental relationships, and enhances the overall functioning of the healthcare system. It’s a skill that, with practice, can significantly elevate the quality of care provided.
Podcast Transcription
Welcome to the St. Emlyns podcast. I’m Iain Beardsell, and I’m Simon Carley. And in this podcast, we’re going to discuss something that we both know you’ll be doing every day in the emergency department. But it’s also something that you may never have actually taken that much time to think about or even been taught. Today, we’re going to talk about how we communicate with each other and communicate with the inpatient teams to whom we’re making referrals.
It’s a really important subject because that interaction with the in-hospital teams will affect how you are able to do the best care for your patients. But also will affect how you are seen by those inpatient teams. And ultimately it will actually make you feel better as a clinician if you do this well. So we’re going to give you a bit of a framework about how you may be able to make these conversations work a bit better. We’re going to try and give you some hints and tips, just little things that can really make the difference between putting the phone down and feeling like you’ve got to where you need to be and putting the phone down and thinking that it just all went a bit wrong.
Now the first thing to say is that at no point are you selling a patient when you’re making a referral. Every referral you make is made because that patient needs ongoing care. And it’s important that the teams you’re referring to understand that this is all part of doing the best for your patient. When you’re making a decision to refer a patient, hopefully you will have made a good decision to take the patient into in-hospital care. You may have discussed it with a senior doctor, you may have looked at one of your local protocols and decided this patient actually needs to be referred. But at that point, you need a sort of sales pitch, it’s not trying to get them to buy something from you. This patient needs care, they need further investigations or further treatment from the inpatient teams. And that is what you’re trying to achieve for your patient. If you keep your patient in the forefront of your mind, you can’t go wrong.
So let’s think about how we’re going to start these conversations. You’ve decided a patient needs a referral. The first thing I would say is take a moment to think about what it is you’re going to say. Now remember that the person on the other end of that line, they may be busy, they may be stressed, they may have all sorts of other people nagging them about the things that they need to do. They may have had a bad day before they got to work, they might have not had any breakfast. There are all sorts of reasons why they could need your help in understanding what it is that you need from them. And I think there’s something about making the early part of the conversation interesting because people like stories. And in some ways you’re telling the person at the other end of the phone a story.
So how do you entice people in that early phase of the conversation that this is something which is going to interest them? Well, I think there’s two really important things here. The first thing is is that when the person answers the phone, answer with your name. Say who you are and maybe give your title where you work. To frame what it is that you’re looking for. So in my case, hi, it’s Ian. I’m one of the emergency department doctors. You’ll often find that our inpatient colleagues decide to introduce themselves with their title. Now I find this a real struggle because that’s not a way to form a team. If you’re forming a friendship or even just a collaboration, you don’t introduce yourself with a title. You say who you are and what your name is. If you’re trying to make a friendship and you go out for a drink with somebody, you don’t introduce yourself with your title. Hi, I’m Ian. Can I get you a gin and tonic and they will say thanks so much. I’m Jennifer. I’d love one. They don’t say hi. I’m a mechanical engineer. Yes, please. They tell you their name.
So use your name to introduce yourself. Now if the colleague you’re discussing this patient with doesn’t use their first name. You need to find a way of finding that out without it seeming too confrontational because it’s really important that we bring this down to a friendship, a team working together. So if they’ve introduced themselves as hi, it’s the general surgical registrar. When you introduce yourself to say hi, it’s Ian. I’m the emergency department doctor. I’m sorry, I didn’t catch your name. This is a non-confrontational way, which they’re then going to have to say hi. Yeah, it’s Simon. I’m the general surgeon and repeat it. Hi, Simon. How nice to speak to you. All of a sudden that relationship is one of friends working together, not of people hiding a little bit behind their job titles.
Now the next thing you need is what I’ve taken to calling the James Bond opening. If you go to the movies, you’ll notice all the big blockbusters start with a big scene. They don’t start with a bit of romance and a little bit of smoochy smooch. They start with a large explosion and they draw you in. They take you into that movie so you want to see more. So tell the person on the other end of the line, the big news that they need to hear. So if it’s a surgeon, tell them exactly what it is about this patient that you need their help with. Now all of this time we’re going to be using what we’re going to call SBAR so that situation followed by background assessment and then recommendations. So this is the situation. So for a surgeon, it might be hi, I’ve got a 25 year old man who I believe has appendicitis. Boom, they need that appendicitis. That’s surgical. Okay, I’m going to keep listening. Don’t start with, hi, I’ve got a 25 year old who came in with a little bit of abdominal pain. He’s had a bit of nausea and vomiting and by now they’re already moving on to the next thing. They’re busy people start with the James Bond opening. Getting them involved in the early phases is really, really important.
So my interpretation of the James Bond opening is what I’m asking people to do is to give a framework at the beginning. There is nothing more frustrating when you’re listening to a history or you’re listening to a junior doctor presented case or you’re on the other end of a phone when people give you a whole series of facts and information, but it doesn’t have any purpose. So Mrs. McGins has come in 65 years old. She lives with a cat at home. Why are we having this conversation? What does this mean? Unless you have a frame, your James Bond opening, I’m worried that this patient has appendicitis. It doesn’t allow the person who’s listening at the other end to tease out the importance of information and to process the information so that they can come back with important questions to clarify. I think it’s really important, as you say, that you get the big message out the framework. Why are we, why are we even having this conversation?
So we’re going to start in our SBAR format with the situation. Now next we move on to background. Now remember that this is just the background to the situation you’ve described. This doesn’t have to be in emergency medicine. The patients in entire background. Remember, we’re always interested in what it is that has meant the patient has come to see us on that given day. We can’t fix all of their medical problems. We want to help them with whatever it is that they’ve come to see us about. So give the background. So in our surgical case situation, this is a 25 year old who I believe has appendicitis. Boom, put a bit more detail behind it. They came in, they’ve had a history of two days of right iliac fossa pain and tell a bit more of the background. It helps confirm to the person on the end of the phone, in this case a surgeon that you know a bit about what you’re talking about. You’ve got an idea about the patient and it gives them a bit more detail and they may then have a few questions they want to ask you afterwards. Don’t forget this is a short interaction. You have to fit this in in a couple of minutes so not giving too much detail. And I think there’s good evidence from research in this area that if you start that conversation, the period between you starting conversation getting interrupted by somebody to clarify some information is actually incredibly short. It will often be within 20 to 30 seconds from you starting talking to somebody interrupting you and asking a question. You might argue that that’s a bad thing and they should shut up in reality. They’re not going to do that. Expect it. Get your big message across early and then expect that interruption and be prepared to answer questions. What you’re trying to do is to generate some ideas in their mind that get some interest in what’s going on and get them interested in looking for the things which are going to trigger actions in them. So in your example, the appendicitis, it might be something like does this person have peritoneal signs? Do they have a raised white count? Do they have a raised temperature? Do they have anorexia? The features that we know are associated with the diagnosis of appendicitis? You should be able to predict what’s going to go on in their minds. Predict what sort of questions they’re going to ask you so that you got them prepared and answerable when they ask. And even better than that, if you can, answer the question before it’s even asked.
The perfect referral is a one way delivery of information which ends with the person you’re talking to saying thank you very much. The more questions that are asked really relates to the lack of information you’ve given that they’ve been asking you. Now some specialty doctors that we work with, we’ve all met them, will insist on showing how clever they are but asking you all sorts of either questions, some of which many of which are probably not of any relevance at all. Take these as best you can, smile sweetly inside. Remember that they’re just stressed and they’re trying to reinforce that they really are the expert and give the information you think is important. If you can, get through to the end without being asked any questions and you know you’ve done a really good job.
So we’ve got the situation and the background. The first two major bits. Next, we come to the assessment. So the assessment phase is what you actually think is wrong with a patient. So in example you’ve given, I think this patient has appendicitis. And that’s a really good reason for you having the conversation because it’s not something you don’t turn out in the emergency department to sort out. It is something that they need to deal with. So it alerts them to the fact that they need to take ownership of this patient. It’s something which is in their domain of practice. And from there you’re then going to move on to the recommendation which clearly follows on from that. Now you might think what’s the point of saying the assessment when it’s just repetition of the situation. But we know, especially from when we’ve done teaching sessions or other stuff, in order to get the important information across there’s no problem with repeating the important facts once or twice throughout the conversation. It just reinforces what’s going on. So don’t be worried that you’re saying things twice if they’re important things. And as Simon says, we then move on to the recommendation. Now this is the point at which you tie it all together and you need to finish off in a way that makes the doctor you’re talking to or the nurse specialist confident that you know what you need. And you can be pretty direct about this. So we’ve had our patient with appendicitis. We’ve given a bit of background. We’ve repeated again. I believe they’ve got appendicitis. Then you need to finish off. So I’d be really grateful if you could see them on the ward. Add in maybe what you’ve done. I’ve made them nil by mouth. I’ve given them some intravenous fluids and painkillers and I’d be really grateful if you could see them on the ward.
Now think about the tone of voice you use when you’re finishing that conversation. Listen to these two examples. I’d be really grateful if you could see them on the ward. I’d be really grateful if you could see them on the ward. The first one implies you know what’s going on and the conversation has come to the end. The second one is a question. We’re not asking questions. This is a one way deliverance of information. So finish confidently and the tone of voice will matter just as it does in all conversation. I think it’s really important to make it very, very clear what you want to do.
Now there is something if you’re really clever. If you want to be very, very smart about this, you can use some of the techniques that people like Cliff Reed. If you want to follow him on Twitter, have taught me. And that’s this concept of illusion of choice. Illusion of choice is a great way to finish off the conversation. You could say I’d really like to see this patient. Would you like to see them on the ward? Or would you like to come down and see them here? Now actually, I don’t care where the patient is seen. I just want them seen. But by giving an illusion of choice to the person at the other end of the phone, they feel that they’re empowered to make that decision. They choose where they want to see the patient. They are in control. They’re not really. But what it means is that they feel that they’re in control of that decision and they take the choice. We get what we want. They appear to get what they want. And illusion of choice is a great way to finish off a conversation.
We’ve got a basic framework for how we’re going to conduct any of these conversations. And remember, you can use this when you’re talking to your consultants or registrars or your colleagues. You can do it hand over time. It’s exactly the same conversation. Situation, the James Bond opening, a bit of background about that situation. Your assessment which may well be the repetition of the situation itself and the recommendations. Be firm in what it is that you want. Make it obvious about what you’re asking that doctor to do for you.
All of this takes practice. It’s not taught. We’re not practicing it. What I would say is there is nothing wrong with just giving yourself a couple of minutes before you pick it up the phone to think through what it is you’re going to say. Because once you get down that path, then it can be really tricky.
Now Simon, it might be just worth us talking about what happens when these referral conversations can go a bit wrong because you need to have some tactics. For when the person on the other end of the phone isn’t quite being as helpful as they could be. Maybe you’ve caught them at a bad time. Maybe there’s other stressors on top of them. Maybe your referral didn’t go so well. What do you do when the person you’re referring to gets maybe argumentative or agitated?
I think the most important thing is don’t engage in an argument. If you are on the end of the phone, it’s very, very easy to just get into a situation where you’re arguing about stuff. You often get involved in minutiae about whether or not a white count is important. Have you done the CRP? What is the result of this test? It can get a bit insane, to be honest. In reality, if there is a serious disagreement about what should happen with a patient, you have a number of options. The first thing is don’t get involved in a fight. Nobody will benefit from this and everybody will get upset. If you genuinely think that you’re struggling to make a referral, end the conversation by saying, “Okay, I just need to go away and think about this.” Then go and discuss it with a senior doctor. Get them to come and see the patient if necessary and give another opinion on what this patient requires. But certainly don’t engage in any sort of difficult conversation. Don’t raise your voice. Don’t get upset. Don’t put the phone down on people. Be polite throughout. You will always do better by maintaining the high ground. Go and review the patient, have another idea, and then after review the senior doctor, go back to the conversation or ask the senior doctor to make that conversation themselves.
Now really, this conversation that you’re planning to have should be in the ideal world, the right conversation with the right person. But as we’ve said, sometimes you just get in a situation where you’re dealing with somebody who’s not on the right wavelength. For whatever reason that might be, don’t get cross with them for that. Have some sympathy with them. We work in a very protected environment in our emergency department. We may sometimes, especially those of us who haven’t done it for a while, forget how difficult life can be on the wards. Some of our tertiary referral colleagues in my hospital are receiving so many different phone calls and so many demands on their time that they need us to try and help them through. So just remember, take a step back, don’t engage in an argument. Just say, I’m really sorry, this appears to not be going very well. Can I just clarify my thoughts with my colleagues and I’ll get back to you in a few minutes and go away and just think again about how you might be able to make that a little bit better. And that’s bound to help. There is no point getting in a fight.
And remember what we said at the beginning, it’s much harder to fight with somebody when you know their first name. And even better, if you get a chance to go to a hospital social, it’s even harder to fight with somebody you’ve had a beer with. And this is why it’s really important as a hospital that you get together with other people and you socialise together because people who socialise together and play together will work together so much more effectively. So it’s an excuse to go to the pub and you can’t really say fairer than that.
In this podcast, we’ve hopefully given you an idea to think again about how you make referrals and how you have these conversations. We’ve got a bit of a framework. We’re going to introduce ourselves with our first names. We’re going to develop a relationship. We’ve got the James Bond opening followed by a bit of background and then repetition of what it is we need. And we’re going to think about the tone of our voice as we end the conversation. The ideal referral is a one way transmission of information with few questions. But if there are questions, we’re going to prepare for those and we’re going to know the answers. And if we don’t know the answers, always be honest and say you will come back or find out for them. There’s no point lying about it. You will always be found out. And last of all, we’ve got some ideas about what to do if things get difficult. Never engage in a fight. It’s just not worth it. But more than anything, remember that this is a skill. Just in the same way putting a central line is a skill or intubating a patient or taking a history or listening to somebody’s chest and it needs practice. It’s not perfect straight away. And when you come to emergency medicine, you will have different tactics that you need compared to when you’re on the wards or working in other specialties. So give yourself the chance to practice. Perhaps do that with colleagues or with your consultants and get some mentorship about how to do it the best you can.
We hope this has been useful. Thanks so much for listening again to the St. Emlyns podcast. There’s plenty more for these topics and others like it on our induction feed and on the St. Emlyns podcast in general. And check out the blog site too and we look forward to speaking to you again soon. Take care everyone.
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