Author: Thomas Wiles / Editor: Charlotte Davies / Codes: CC15 / Published: 31/07/2018
Can I…ummm…refer…umm…a 52, no a 55, no, a 69-year-old lady presenting with chest pain. Well, she said it was chest pain, but it’s actually a wierd tightness, with a bit of epigastric pain. It started last Tuesday when she was watering the garden. She bent down, and the pain started. So she had a cup of tea. Umm. And it still didn’t go. She’s got no medical problems but takes GTN spray occasionally, and aspirin. I wasn’t sure what was going on, so thought it was safest to refer to you. But she doesn’t want to come in because she’s got two cats Poppy and Seed who need feeding tonight.
Sound familiar? We’d like not to refer patients like this, but unfortunately we all do! Making a referral is a fundamental skill that we are required to have in order to provide safe care to patients in our ED’s. Despite this, I was never formally taught how to do this during any ED induction programmes during my training. I can recall making unclear and poorly communicated referrals as a result. Having overheard many referrals made by others in our ED I know that I was not alone in feeling underprepared as a trainee, and that this is an art that we all need to develop as ED doctors.
In the first few weeks of your first ED placement, there is a steep learning curve as you work out which patients need to be referred, which specialty to refer them to, how the referral pathways work in your ED and how to articulate your referrals in order to make the process run smoothly. In this blog, I shall try to describe some lessons that I have learnt from trial and error over the last fifteen years. It is based on personal experience and is by no means definitive. I encourage you to check out all the references listed at the end.
The first thing to consider is why we make referrals from the ED. Here are the main circumstances in which I think that we make referrals:
- A specialty has a skill that we don’t have (e.g a surgical procedure or an imaging investigation)
- A specialty has knowledge or experience that we don’t have (e.g. the ongoing care of an acute condition after initial management/resuscitation in the ED)
- A specialty has access to a resource we don’t have (e.g a bed space on a ward for a patient to receive a few days of intravenous therapy)
There may also be rare occasions in which we ask a specialty doctor to perform a skill that we can do in the ED if the acuity of other sick patients mean that we cannot provide an EM doctor to perform the technique. This might occur in the early hours of the morning when there may be just one EM HST or middle grade working with more junior colleagues.
It should be rare for you to have to ring a specialty colleague to ask for advice on patient management. All advice should initially be provided by your senior colleagues in the ED (they will have a wealth of knowledge and it is unlikely that the advice you require cannot be provided by them). However, if they do not know the answer to your question they may suggest that you speak to another specialty.
The other issue to be aware of is that the person receiving the phone call is likely to already have a large amount of work to do, and the last thing they may want when they speak to you is to have another referral to see. This is no excuse for them being rude or obstructive but we should be aware that we are not the only specialty in which demands upon us are extensive.
So here are some tips which I think will help you make excellent referrals:
- Always be polite. This should go without saying and should be maintained even if we believe the person we are referring to is being unhelpful.
- Give the patient’s name to them before you present the clinical features. I believe that once they have written the patients name down on their “to see” list, psychologically they have already started to take some ownership of that patient’s care, and this seems to smooth the process somewhat.
- Summarise the history and examination findings succinctly and leave in only the features that are relevant. It may be worth preparing what you are going to say by writing up your clinical notes before you make the referral.
- If you ask a senior EM colleague for advice and they tell you to refer the patient on to a specialty but you do not fully understand why you have been asked to make that referral, politely ask your colleague to explain to you exactly what you need from that receiving specialty. If you are referring a patient who has been reviewed by one of your consultants or seniors, explain this to the person receiving the referral.
- Be explicit about what you expect of the person that you are referring to. If you only require advice say so, if you want them to see the patient make that clear to them.
- Acknowledge that the person to whom you are referring may have lots of other things to do. I often start my referrals by saying something like “I’m afraid that I have another referral for you to see”.
- Consider if there are things that you can do that will benefit the patient on behalf of the specialty you are referring to. This may include investigations. You could offer to organise for them to have been performed before they see the patient.
- There are some occasions when you will be asking a colleague to verify or perform a procedure or investigation that you have requested via your hospital’s electronic system (e.g. a CT or endoscopy). Under these circumstances, it is better to say that you have requested the investigation/procedure rather than ‘ordered’ it.
- Make sure that you don’t make any promises to the patient in expectation of what the receiving specialty may do (unless you are absolutely sure of what will occur). This will reduce the possibility of complaints later if expectations are not met.
- Do not allow the person receiving the referral to tell you to do something (e.g. send the patient home) if you are not comfortable with it. Find a senior colleague and discuss what you have been advised.
- Do not get into any arguments with a specialty colleague. If they decline to see the patient you are referring to them and you cannot persuade them otherwise, politely end the conversation and discuss with your senior EM colleague (ideally a consultant). It may be that the person you are referring to is correct, if not, any further discussions with them should be made by your boss.
- Follow up your patients later and keep track of their clinical course. Electronic notes have made this process much easier and allows us to check whether our impression and decision making was correct in the hours, days and weeks after our patient contact in the ED.
For further reading please look at the following resources:
St Emlyns: Making a referral with Iain Beardsell
Life in the Fastlane: Referring Patients from the Emergency Department
Academic Life in Emergency Medicine: MEdIC: The Case of the Difficult Consult Expert and Community Response