QI Pearls: Consultant Communication
March 2024
Author: Dr. Gregory Han MD PGY2
Peer Reviewers: Dr. Reena Sheth MD PGY3, Dr. Victoria Pereira MD PGY2
Faculty Editor: Dr. Christie Lech, MD, MPHE, Assistant Professor of Clinical Emergency Medicine Weill Cornell Medical College, Cornell University
Case: An 85-year-old woman presents to the ED with acute left sided weakness. A “Level 1” stroke code is called and, after initial CT scans did not demonstrate an acute bleed, a tissue plasminogen activator (tPA) is administered. However, she subsequently develops a headache and is rescanned, showing a post-tPA bleed. Neurology, neurosurgery, and hematology are immediately consulted, and arrangements for transfer to the neuro ICU are immediately begun. Due to logistical delays, the patient is kept in the ER for >8 hours during which time her mental status deteriorates.
Multiple teams (EM, neurosurgery, neurology, and hematology) are involved in this patient’s care throughout this extended duration. Multiple Epic Chat and in-person conversations were held about the patient’s care plan, with some recommendations being made to either the ED or the NICU team rather than all involved teams. As a result, the administration of the appropriate prothrombotic/TPA reversal agents may have been delayed. The patient becomes obtunded and is intubated for airway protection in the ED before subsequently passing away in the NICU.
Background:
Consults are an invaluable resource in the ED; consultants use their focused expertise to advance patient care. However, adding more members to a patient’s care team makes decision-making more complex, as the primary team must apply their consultants’ recommendations to their own first-hand knowledge of the patient. This is especially important for the care of critically ill patients, where margins of error are smaller and many decisions are more time-sensitive. It is very important to optimize and streamline consultant communication in the emergency room.
What does the literature say?
A qualitative analysis by Kessler et al. highlighted the importance of organizational skills, communication skills, and medical knowledge when requesting consultants in the emergency department. They summarized these into the 5 C’s of Consultation: contact, communication, core question, collaboration, and closing the loop.[1] They followed this up by testing residents and medical students on simulated consults, comparing those who had undergone training they structured around these themes.[2,3] Their third party reviewers found that those trained on this model were more comprehensive when making initial consult requests over the phone.
The literature also contains pearls on how to be a more thorough consultant. For example, the Ten Commandments of Consultation are:[4]
Determine the question that is being asked
Establish the urgency of the consultation
Gather primary data
Communicate as briefly as appropriate
Make specific recommendations
Provide contingency plans
Understand their own role in the process
Offer educational information
Communicate recommendations directly towards the requesting physician
Provide appropriate follow-up
How do we act on this as Emergency Medicine providers?
The consulting question should be clear.
The consulting process is a collaboration between two or more teams with distinct roles.
It is important that the consulter gets the consultant’s recommendations directly.
Give a clear consulting question
We should ensure our consulting questions are well framed. Don’t consult someone if you’re not sure what the question is; clarify that with your own team before sending the consult. It could be as simple as “I have a patient with appendicitis in the ED” or it could be more open-ended, like “help me work up this patient’s leukocytosis to >100,000 without a clear source.”
Use closed loop communication
Use closed-loop communication to ensure that you and your consultants are on the same page. After they have given you recommendations, repeat what you’ve understood back to them. This gives both sides the opportunity to correct any errors in understanding, such as disambiguating any jargon that might cause something key to be lost in translation (e.g. dosing of uncommon medications and specialty-specific acronyms). It is also an opportunity to voice disagreement, such as if the emergency medicine team feels the consultant’s recommendations are inappropriate. This is especially helpful in high stakes situations such as strokes, resuscitations and traumas.
Establish the consult’s urgency
Ensure that your consultants understand how urgent a consult is. Unstable patients may need an answer from your consultant immediately and your consultant needs to know that. Furthermore, if a patient takes a turn for the worse, your consultants should know! Sometimes the situation requires all hands on deck. You may need to ask your consultant to come to the bedside, and that’s ok.
In the modern day of Epic Chat/EMR-based texting, we also recommend the following guidelines:
The primary team should be in any chat where consultant recommendations are being made.
Minimize the number of side chats and make sure that one chat is open with all involved parties (e.g. primary team, consultants, social work, bed assignments).
Unlike phone calls and in-person conversations, EMR texts are part of the medical record! Make sure to always be professional.
Case conclusion
The care of complex and critically ill patients requires close coordination between the emergency medicine team and several other services. Effective consultant communication in these situations requires clarity, a shared mental model between the consultant and primary team, and comprehensive communication by all team members. In this post-tPA bleed case, there were multiple consultants providing recommendations to the primary team (ED) as well as to the receiving inpatient team (NICU). Ensuring that all recommendations reached the ED team, such as by directing all conversations to a main EMR Chat with all consultants and the team, may have helped by minimizing side conversations. Whenever interdisciplinary conversations are being held, use of the 5 C’s, particularly closed loop communication is crucial. This is especially true for unstable and critically ill patients.
References
Kessler, Chad, Bradley M. Kutka, and Christian Badillo. "Consultation in the emergency department: a qualitative analysis and review." The Journal of emergency medicine 42.6 (2012): 704-711.
Kessler, Chad S., et al. "The 5Cs of consultation: training medical students to communicate effectively in the emergency department." The Journal of emergency medicine 49.5 (2015): 713-721.
Kessler, Chad S., et al. "A prospective, randomized, controlled study demonstrating a novel, effective model of transfer of care between physicians: the 5 Cs of consultation." Academic Emergency Medicine 19.8 (2012): 968-974.
Goldman, Lee, Thomas Lee, and Peter Rudd. "Ten commandments for effective consultations." Archives of internal medicine 143.9 (1983): 1753-1755.
