How to make an inpatient referral

1. HOW TO MAKE AN INPATIENT REFERRAL

2. I’M CALLING FROM ED WITH A REFERRAL…
 Identified need for admission/inability to
discharge safely
 Select appropriate inpatient (hopefully
specialty) team to admit under
 Don’t forget about other specialties that
aren’t listed in the daily roster! (i.e.
rheumatology)

3. DECISION TO ADMIT – ED VS WARD BASED
 1995 study of 1200 patients in Belfast
 Comparison between ward teams and ED teams and decision to admit:
 No significant differences in rate of diagnostic error
 No significant difference in inappropriate admissions
BMJ 1995; 310 doi: http://dx.doi.org/10.1136/bmj.310.6988.1199 (Published 06 May 1995)

4. STRUCTURED CLINICAL HANDOVER TOOLS
 ISOBAR
 Identify
 Situation
 Observations
 Background
 Agree to a plan
 Read back
 ISBAR
 Identify
 Situation
 Background
 Assessment
 Recommendation
 S-BAR
 Situation
 Background
 Assessment
 Recommendation
 SHARED
 Situation
 History
 Assessment
 Risk
 Expectation
 Documentation

5. ISOBAR
 Identify: yourself and the patient
 Situation: reason for handing over/referral
 Observations: vitals/assessment
 Background: pertinent patient information
 Agree to a plan: given the situation, what needs to happen
 Read back: confirm shared understanding

6. AUSTRALIAN PATIENT REFERRALS FROM ED TO INPATIENT TEAMS
 3 distinct factors to negotiating TOC
 Variations in clinical information required
 Culture of the organization and of clinical teams
 Characteristics of individual participants
 Implied, if not literal, power to accept or reject ED referrals
 Imbalance of power is reinforced when the ED physician is junior to the inpatient clinician
 Success of referral depended on speaking/listening abilities of all parties
 Politeness of requests/responses, tone of voice ± body language
 Referrals are more likely to be accepted if patient has a condition of interest to the receiving team
 Both parties perceive they have something to gain from the outcome
 Referrals to private hospitals almost always welcome and accepted with few reservations due to financial and professional
reasons
Lawrence S, Spencer LM, Sinnott M, Eley R. It Takes Two to Tango: Improving Patient Referrals from the Emergency Department to Inpatient Clinicians. The Ochsner Journal. 2015;15(2):149-153.

7. REFERRING PITFALLS
 Any semblance of choice in accepting or declining review
 Pt with extensive hx of ulcers and known to vascular sx, who was referred in by a private vasc. consultant for admission…
ED was asked to not admit this patient or if needed admission, for MAU
 Don’t want to accept the patient? See the patient, and you can then re-refer to another team if you wish.
Referrals are one way!
 “We don’t do tele-health.” –Tor
 No clear identified reason for referral
 Private vs public
 Permitting further investigations to prevent specialty referral
 JHC ED referral to SCGH ED for a neurosx pt query cauda equina without MRI, as neurosx ROC refused to TOC
 Nice, but firm!

8. COMMUNICATION SKILLS
 Be succinct
 Ask open-ended questions
 Communication occurs most effectively when both parties are or think they are at the same level
 Maintain self-worth even when communicating with senior parties and be an active listener
 Communication flow is “uphill” and less successful if one takes a subservient approach

9. COMMUNICATION SKILLS
 Acknowledgement, validation, or identification
 I can see you’re upset about this
 Most people would be upset about this
 I would be upset about this too
 Acknowledging the situation makes it clear that one understands how the other perceives it, and makes
it safe to discuss it
 If you make it clear that you do understand another person’s view of the world, there is usually very little
to argue about even in disagreement

10. COMMUNICATION SKILLS
 Maintain self-control to avoid escalating the problem
 Separate the person from the issue; be soft on the person and firm on the issue
 “I want to talk about what the issue is, but I can’t do it when you’re yelling. Let’s discuss the problem civilly.”
 Reduce personalizing other people’s behaviours
 “It must not be easy…”
 “I feel…” vs “you make me…”