Updated: Aug 18, 2020
The intention behind this blog is to provide some helpful tips for our new SHOs with regards to surviving and doing well during your time in the Mater Hospital Emergency Department. While the induction videos provide a great deal of useful information regarding clinical aspect of work in ED, I wanted to use this thread to share some 'off-label' advice on key ED processes, based on personal experience and observation of common mistakes. I hope it will prove useful and hopefully it will generate further discussion.
Referrals So you have assessed your patient, done appropriate investigations, produced a diagnosis, and now comes the awkward bit of convincing a fellow SHO to 'accept' the patient. I remember dreading this part throughout my early years in ED, and this is where I often see people getting stuck in, with in-house teams not being particularly helpful on occasion. Being a key process in ED, referral quality has major effect on patient flow and hospital experience, while inefficient referrals often lead to unnecessary investigations, prolonged time in ED and potentially result in negative interactions between colleagues.
In my experience, an efficient referral is based on 2 key elements:
1. Good understanding of "why this patient needs to come in"
- Heard this question before, right? The answer stems from good patient assessment and differential diagnosis. Treatment pathways of most conditions are guided by gold standards that are accepted and agreed-upon by specialities on senior level. Therefore, once your clinical impression is accurate, it will enhance the understanding of what treatments / investigations are required and why hospital admission is (or isn't) the next logical step.
The biggest trap that I see new docs set for themselves is to pick up the phone without a clear answer to that question. That often leads to requests for unnecessary investigations and speciality consult requests from the other end of the line, resulting in admission delays, avoidable handovers and personal frustration. When in doubt - run your case by one of the seniors and confirm your plan. If a senior ED doc did not ask about a particular investigation after you presented a case - it probably is not required to initiate patient admission process.
An alternative and flipped version of this question that can highlight your perspective is "why this patient cannot go home". That can be often backed by various clinical scores (CURB-65, HEART, ABCD2, etc...) and details from patients social history. Again, a senior colleague should be able to provide guidance on request. If the in-house team strongly believes that the patient is better managed at home, they have equal powers to discharge the patient based on their expertise...
2. Well-structured communication
You have managed a complex case, figured out a sound diagnosis backed up by imaging/ bloods and gave life-saving treatment while solving countless problems that stood in your way. Excited, you pick up the phone to share your achievements with a fellow in-house doc keen to get them to take over care... only to find your enthusiasm tempered by their lack of case understanding, based on the excited gibberish that you just produced on the phone! Does that sound familiar? Probably...
A common misconception during referrals from ED where things are often turbulent, is that that your colleague on the other end will be on the same wavelength, ready to jump into action just where you left it. In reality, they have not experienced the events that you have seen in first person while managing a patient, and their insight into the case depends entirely on your choice of words over the phone. In my experience, the most important thing that can be done to increase the chances of successful referral is to take 30 seconds or so to summarise your case before referring it to another specialty. Just like in long cases back in med school, where a bulk of your grade lies in good presentation of your findings. Bear in mind, that a person on the other end of the phone may be focused on something else when they receive your call, and it will take moments before they will fully engage with you. We're all familiar with ISBAR tool - use it to add coherence to your referral. Measure your pace and highlight the important findings, problems and expectations from your side.
Read this journal article
Thanks for enagaging!
Peer review - Cian McDermott