Sadly we cannot care for everyone in our small rural hospital – oftentimes patients may need an investigation which we cannot offer (eg CT scan, angiogram) or have complex needs requiring tertiary level care.
So we often need to talk to our metropolitan colleagues to arrange transfer – whether by commercial carrier, RFDS fixed-wing or occasionally rotary-wing retrieval with the excellent medSTAR.
I was taught ISOBAR (recently contracted to ISBAR) for handover – not a bad tool. I like it because it introduces a level of both formality but also structure to our communication.
Identify (yourself and patient)
Situation (brief description of the problem)
Observations (relevant obs)
Background (relevant PMHx)
Assessment (what you think is going on)
Response/Readback (what needs doing & a verbal readback of handover)
But this doesn’t always happen.
This week was a classic example; I had to transfer a patient up to town with an acute abdomen. After a few minutes at switchboard, I was put through to the Duty Surgical Registrar.
Me : “Hello”
DSR : “Yes?”
Me : “Hi there. It’s Dr Tim from Kangaroo Island. I need to talk to you about a hospital patient with an acute abdomen. Is that the duty surgical registrar?”
DSR : “….”
Me : “Hello?”
DSR : “…yes?”
Me : “Are you the duty surgical registrar”
DSR : “Have you spoken to ED?”
Me : “No, not yet – this patient has a surgical problem and I need to tell the surgical team – are you the registrar I need to talk to?”
DSR : “I am on for hepatobiliary”
Me : “Great. Does that mean you are the admitting surgical team of the day?”
DSR : “……maybe. Has he been seen by Emergency?”
Me : “No. He would be an interhospital transfer. I don’t want to dump him in ED, he needs to be seen by the surgeons. Can I tell you about this patient?”
DSR : “I am on for Hep-Bil until 5”
Me : “OK, he’s a 72 yo man with a 24 hr history of acute abdominal pain, jaundiced, raised LFTs and requiring opiate analgesia. Clinically I suspect pancreatitis and want to ….
DSR : “Just send him to emergency”
Me : “Oh….OK….can I just get your name, so that ED know who I have spoken to”
DSR : CLICK – HANG UP
So much for ISBAR.
I don’t want to ‘point the bone’ at any particular hospital doctor or specialty – or indeed fellow primary care doctors. We all have bad days, we are all busy.
It is more of a system failure than an individual failure – so we need to embed tools like ISBAR into our day-to-day work…a sort of ‘handover checklist’ if you like.
This is important, as I reckon many medical errors are due to failure to communicate between clinicians. A recent Coroner’s report from communication failure is illustrative.
Regardless of who is at fault, we all need to do better.