Emergency Department Consultation: Improving Communication Between Health Care Providers
Chad Kessler, MD, MPH, Section Chief, Emergency Medicine; Jesse Brown VA Hospital, Clinical Associate Professor, Departments of Emergency Medicine, Medical Education, and Internal Medicine, University of Illinois at Chicago College of Medicine.
Alexandra Asrow, MD, Department of Emergency Medicine, Resurrection Medical Center, Chicago, IL.
Steven M. Winograd, MD, Department of Emergency Medicine Core Faculty, St. Barnabas Hospital, Bronx, NY, Albert Einstein Medical School, Bronx, NY.
Communication within the team is essential. Vital information is often lost during transitions of care. Even when the same team is caring for the patient, communication about the care plan is important. This article is about one of those situations, when we call in a consultant.
Sandra M. Schneider, MD, FACEP, Editor
Consultations and transitions in patient care have become hot-button topics recently, with increasing focus on patient safety,1 efforts set forth by the Joint Commission's SHARE project,2 and new 2011 ACGME work-hour policies for residents.3 Additionally, consultations are under heightened scrutiny in terms of resource utilization in increasingly overcrowded, tightly budgeted emergency departments (EDs).4
Many publications have highlighted the crucial importance of communication and education to safe and effective consultations and transitions of care.1,5-8 While ACGME core competency guidelines state that residents must be able to successfully demonstrate effective information exchange and communication with other health care providers, the essence of consultation,9 no widely accepted consensus exists on the types, elements, best-practice standard methods, or educational guidelines for consultation from the ED.
This article will discuss the elements of ED consultations and present examples of standardized methods for consultation that may be useful in any ED. Additionally, the implications to medical education and patient safety will be discussed, as well as future directions for research on the topic.
Importance of Consultation in the ED
According to the 2007 CDC National Health Statistics report, there were 117 million visits to EDs in the United States,10 a number that has been steadily growing by 23-32% during the past decade.11,12 Of these visits, 20-40% of patients admitted received at least one consultation from the ED.4 With millions of consultations occurring each year, the aforementioned changes in work hours, increasing patient volumes, and increasing focus on patient safety, consultation, and transition of care in the ED is of obvious importance.
Consultation has been defined as a "service type provided by a physician whose opinion or advice regarding evaluation or management of a specific problem is requested by another physician or other appropriate source."13 In other words, it is a conversation, an exercise in communication between two health care professionals, and herein lies the crux of the source of risk and mistakes.
Challenges and Pitfalls in Communication
On average, ED staff deal with 42 distinct communication events each hour,14 with interruptions every 9 minutes for attending emergency physicians (EPs), and 14 minutes for residents.15 This occurs in combination with crowded waiting rooms and EDs, pressure to "move the room," and variable availability of consultants. In fact, a 2006 American College of Emergency Physicians (ACEP) survey reported that 73% of physicians had problems with inadequate coverage by specialist physicians, which had increased from the 67% reporting the same answer in 2004.16 Additionally, in the same survey, 38% of physicians reported that physicians in their ED were spending more time placing calls to consultants during the year, which was increased from the previous year.16
Table 1: Key Facts and Statistics on Consultations and Communication9-12,16,22,24
- There were 117,000,000 visits to EDs in 2007, with growth of 23-32% in past decade.
- 20-40% of patients admitted from ED receive 1 or more specialist consultations.
- 73% of EPs report problems with inadequate coverage by specialist consultants.
- 38% of EPs report spending more time placing consultations in past year.
- The majority of EPs believe residents receive inadequate training in consultations.
- ACGME requires written documentation of communication core competency.
- 29% of EPs specifically note lack of clear consultation protocol.
Our hectic, multitasking environment with overlapping patients, interruptions, performance pressures, unreliable availability of consultants, and extremely limited time available to place consultations poses great challenges to satisfactory and patient-safe communication between EPs and specialists. Yet, the number of patients and consultations continues to rise. These factors also pose practical challenges to forming lasting and cooperative relationships with consultants with whom conversations and coordination of patient care frequently occur. Combined, these factors create the perfect storm for potential errors.
Errors in communication have long been statistically identified as major sources of risks to patient safety by many publications and authorities. These errors may lead to increased mortality and health care costs,17 clinical errors, and delays in treatment.1,2,18,19 Specific sources for these gaps in communication have been suggested to be related to ambiguity in individual responsibility,20 consulting physicians having inadequate knowledge of the patient, providing inaccurate or incomplete information to the consultant, the inability to contact the consultant,5 and all of the environmental influences discussed above. Problems as seen by consultants may include, but are not limited to, being unaware of a patient transfer, having little knowledge of the patient being transferred, and the inability to follow-up with the treating physician for additional information.5 With all of these challenges, it is important to keep in mind that the purpose of the consultation is communication. It is a crucial step in medical decision-making, definitive patient management, advice, transfer of care, disposition, and, as a result, patient outcomes, satisfaction, and safety.
To address these and other dangers and pitfalls involved in communication, it is important to highlight the role of education for ED staff, to promote recognition of potential hazards of transitions, and to see consultations and transfers of care as opportunities to initiate corrective actions, not merely transfer responsibility.21
Communication in Medical Education
Teaching communication skills has been lacking in most residency programs. Yet, interpersonal communication is included as a key component in the ACGME core competencies for all members of graduate medical education programs.9 This includes a requirement for written documentation of trainees' level of competence in interpersonal communications.9 Yet, one recent survey found that the majority of EPs believed residents were inadequately trained in consultations,22 and many physicians struggle to learn this skill on the job.19,23 Multiple publications have recommended utilizing educational tools to improve skills and minimize errors in medical communication interactions, such as consultations and transitions of care.1,5 Yet, unlike nearly every other core aspect of medical education, such as patient history or physical exam, no standardized format exists for conducting or teaching consultations or transitions of care. In fact, in a survey of EPs, 29% actually noted a lack of a clear consultation protocol.24
This lack of standardization is a major factor hindering effective medical education on consultations; however, other limitations have been identified as well. These include ambiguous definitions of communication skills, failure to identify learned behaviors that translate and persist in clinical situations, and lack of objective evaluation of this competency as compared to similar diagnostic skills.15,25 The net result is a nebulous and inefficient instruction system for crucial communication skills, producing a wide range of styles and reliability of EP consultations and transitions of care. It seems nobody is sure what to teach, how to teach it, and how to assess knowledge and understanding. Yet, residency programs still need to satisfy this important ACGME core measure. This permissiveness can lead to serious breaches in patient safety, cost-efficiency, satisfaction, and cooperation, as discussed above. Additionally, the resultant wide variation in practice makes improving specific and measurable objective patient outcomes in relation to consultations and transitions of care difficult.
Areas for Improvement in Communication, Consultations, and Transitions
Having a clear understanding of the importance communication plays in consultations and transitions of care, and the negative effect the current state of variable education and practice can have on patient safety and outcomes, the next step is to identify targets for improvement and methods for doing so. Analyzing what constitutes effective communication is essential because it is a key factor in providing safety and good outcomes to patients.26-31 Transitions in care are "vulnerable moments in emergency care for many reasons, including physical and psychological noise, lack of a backstage, bias for certainty, unwillingness to question prior judgments and decisions, and a lack of resolution to empirical questions due to face concerns."18
To begin, one seemingly obvious yet often overlooked element in successful communication is the simple act of introducing oneself by name and learning the name of the consultant with whom you are speaking.32 This basic step creates a personal foundation for any communication that follows and provides the basis for establishing an ongoing professional relationship and an environment of teamwork with consultants. Fostering a teamwork relationship and line of communication is crucial given the growing numbers of consultations being placed by EPs nationally. By increasing rapport between professionals and satisfaction at the workplace, it may be possible to foster better communication, thereby avoiding errors and improving patient safety and outcomes.
SBAR (Situation, Background, Assessment, Recommendation) is a tool widely used by nursing and many non-healthcare fields to transfer information.33,34 First, define the situation or problem and indication for communication. Second, share all necessary background information and confirm that all parties have understanding of the situation. Third, all parties agree on an assessment of the situation. Finally, create and agree on recommendations to address the assessment. This method has been shown to produce less missed information and improve satisfaction and confidence in communication when used in medical settings.33,35
Interestingly enough, these steps also specifically address many of the sources of dissatisfaction and errors in communication as identified by physicians mentioned earlier. These included inadequate knowledge of patients, inaccurate or incomplete information given to the consultant, and consultants having little knowledge of the patient in question.5 Additionally, one study specifically identified improvement in utilizing and translating pertinent information in communication as a specific area for improvement in transfers of care.18 This information may come from multiple sources, including EMS, nursing homes, etc., about situation, medical and social history, and any other reliable sources of information available to the EP. Gaps may occur in an attempt to accurately synthesize and transfer information from such a variety of sources. The same publication also suggested implementing conversation techniques that allow feedback between team members and cause mental reflection on previously made decisions to reduce anxiety and uncertainty in sharing information.18
So, where do we begin to remedy these sources of error, variability, and gaps in communication? The first step is to educate students, residents, and practicing physicians to implement changes to the current state of communication between EPs and consultants. However, in order to standardize this process, best practices must be established for placing a consultation. Many sources have called for such a standardized method,1,2,35,36 yet no current consensus exists as to a specific protocol. SBAR has been shown to be an effective tool in communication, but does not provide the level of detail required in complicated consultations and patient transfers for physicians. Based on preliminary data and ongoing research in support of the effectiveness of this approach, the next section presents one possible conceptual framework for consultation between physicians and, in following, provides a framework for future research and improvements in patient safety.
Table 2: Elements of the Joint Commission SHARE Initiative37
Standardize critical content, including
Hardwire within your system, including
Allow opportunities to ask questions, including
Reinforce quality and measurement, including
Educate and coach, including
Standardizing the Approach to ED Consultations
To begin formulating the essentials of a standard method of consultation, the elements of the SHARE project36 through the Joint Commission are a useful resource both for guidelines, and to remain in line with educational goals for trainees in communication. Designed to identify barriers and solutions to challenges in communication, the acronym SHARE breaks down as follows (see Table 2):
S: Standardize critical content;
H: Hardwire within your system;
A: Allow opportunities to ask questions;
R: Reinforce quality and measurement;
E: Educate and coach.
With these useful guidelines in mind, using a business model as a framework38 and a detailed qualitative analysis of ED consultations, a modified-Delphi method process led to the development of a consultative method called the "5 Cs of Consultation."
Table 3: The 5Cs of Consultation and a Decription of Each of the Components that Should be Considered When Preparing for a Successful Consultation
Introduction of consulting and consultant physicians and building of relationship. Identify with full name, rank, service, and name of supervisor.
Give a concise story and ask focused questions. Communicate concerns, urgency of matter, timeline.
Have a specific question or request of the consultant. Decide on reasonable time frame for consultation.
A result of the discussion between the emergency physician and the consultant, including any alteration of management of patient or testing.
Closing the loop
Ensure that both parties are on the same page regarding the plan and maintain proper communication about any changes in patient's status.
The 5Cs are as follows: 1) contact; 2) communicate; 3) core question; 4) collaboration; and 5) closing the loop. (See Table 3.) This model not only addresses the guidelines of the SHARE initiative, but also the other pitfalls and sources of error in communication discussed in this article. It provides a means of structuring a consultation to improve the efficacy of communication, to clearly define the needs of the consulting physician and consultant, and sets a specific time frame for the consultation to occur. Before placing the consultation itself, the EP must gather as much information on the case as possible to provide a complete story. This is a crucial step to the process, as inadequate information was discussed previously as a major source of error. This can be viewed as an additional precursor "C," for "collecting information." Additionally, the EP must clearly identify the goal and question at hand necessitating the consultation, and confer with colleagues and team members in the ED as necessary to ensure that everything is in place and nothing is forgotten during the conversation with the consultant. When the EP is fully prepared with this information, the 5Cs come into play when placing the phone call to the consultant. (See Table 3 for a detailed description of the 5Cs.)
The following is an example of using the 5Cs in a sample consultation from the point of view of the EP who is speaking to a consultant. The EP is using the 5Cs:
Contact: "Good afternoon. My name is John Smith. I am an ER doc here. With whom am I speaking?"
The consultant answers.
Communication: "I have a 45-year-old G4P4 obese female with nausea, right upper quadrant (RUQ) pain worse after fatty meals, and vomiting. She is febrile to 101.4, has focal right upper quadrant tenderness to palpation, and a mild leukocytosis of 14. Bedside RUQ ultrasound reveals pericholecystic fluid and gallbladder wall thickening. I believe the patient may have acute cholecystitis and will likely need antibiotics and cholecystectomy."
Core Question: "I am consulting you for the evaluation of suspected cholecystitis and possible surgical procedure. Could you please come down in the next 30 minutes to assess the patient and offer recommendations?"
The consultant makes recommendations.
Collaboration: "I'm happy to obtain a formal ultrasound of the RUQ while you make your way out of the operating room and to the ED."
Closing the Loop: "I appreciate your help. The ultrasound will be ordered stat, and we will expect to see you in the ED in the next 30 minutes or so. Thank you so much."
Following any consultation, it is important to document the conversations. This is not only for patient safety, but for medical liability protection. Be sure to document the name and the time the consultant is called, the time he or she answers, and the agreed upon timeframe and action. Also note the time the consultant arrives in the department to assess the patient. The 5Cs provides a framework to simplify this process. The communication, core question, and collaboration steps provide information for the body of the note documenting the consultation, and Close the loop provides the plan of care to record in the chart. This process provides both a complete, quick, and easy basis for an accurate record, and a useful referral for the busy EP when re-examining the patient, and planning disposition or admission to the hospital.
Using the 5Cs significantly improves satisfaction and performance on consultations for both the EP and consultant. This method may be used to address many of the sources of errors in communication discussed above, and demonstrates promise to be developed as a standard best practice in consultation.
Disposition of Consultations: Future Directions, Research, and Implications
With the communication factors in mind, and the 5Cs method of consultation and other tools discussed, where do we stand and what are the implications for the future of consultation? It seems a fair assumption that improving consultations and patient handoffs will improve patient safety outcomes and other measurable endpoints. However, due to the difficulty in studying these outcomes without a standardized consultation method, there is currently no meaningful body of evidence on the subject. Therefore, the next logical step would be increased research assessing critical gaps in patient safety, medical errors, and resource utilization, with a focus on medical education.36 (Table 4 includes a brief list of future research directions relating to consultations and the 5Cs.)
Table 4: List of Future Directions for Research Questions and Development of Advances in the ED Utilizing the 5Cs Method of Consultation
- In person vs. online based training
- Patient and physician self-reported satisfaction with method
- Response time to consultations
- Time spent on consultations by EPs and consultants
- Number of tests ordered
- Length of hospital stay
- Differentiating elements of types of consultations - building taxonomy of consultation
- Cost-efficiency and resource utilization of different types of consultations
- Possibility of core consultation measures
- Medico-legal implications of standardization and core measures
Consultations are an exceedingly important part of practice in the ED, with nearly half of all admitted patients receiving at least one consultation as part of their care. With ED visit numbers growing each year, increased pressure for throughput and cost reduction, and focus on patient safety and reducing medical errors, it is clear that consultations are an important place to focus.
The essence of consultation is communication, a broad subject with great importance to medicine, as recognized by the ACGME in their core competencies. In terms of consultation itself, there are many sources of error in communication. These include lack of foundation in conversation between professionals, incomplete information relayed through the consulting physician, availability of consultants, incomplete understanding or knowledge by a consultant that a consultation or transfer of care is being conducted, and many outside environmental factors affecting both parties in and out of the ED. There are numerous areas for improvement in communication, many of which are addressed by the SBAR method for transfers of care and the Joint Commission's SHARE project.
There is a great need for a standardized method of consultation to improve both education and outcomes for patients. In addition to SBAR and SHARE, the "5Cs" method of consultation contact, communicate, core question, collaborate, closing the loop is a useful tool designed for physicians conducting ED consultation that addresses many of the identified challenges and pitfalls in communication. Utilizing such a standard method also opens the door to investigate patient safety and outcomes in consultation and transfers of care. The method utilized for communication may need to be adapted to different types of situations, and patient outcomes may be affected accordingly. With these issues in mind, patient outcomes, including satisfaction, treatment times, resource utilization, safety, and medico-legal endpoints, are some important examples of areas that may benefit from standardization of communication methods. Consultation and transfers of care are a promising field for great accomplishments in the near future, both clinically and academically.
Overall, the important take-home points are as follows. Consultation is a cornerstone of emergency medicine, and increasingly important in today's busy ED. Communication is crucial to patient safety and outcomes, and a source for many errors and pitfalls. Identifying a standardized method of consultation is an important way to reduce these errors and to provide a framework for meaningful study of patient- and hospital-related outcomes relating to consultation. The 5Cs represent an effective method of standardized consultation, and have potential to serve as the basis for best practice, improving patient safety and outcomes, and facilitating important research in the field.
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