Communication Failure

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.

http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/545/MAY%20Terrill%20Anthony.pdf

Regardless of who is at fault, we all need to do better.

Comments

  1. says

    Great post TIm, I have a rural GP registrar guide for sending patients from the country in the pipeline. Luckily I havent had this problem with the speciality (ie. partialist) team. To be honest I have usually spoken to ED about acute abdomens

    Gerry

  2. says

    I think the mantra should be:
    Slow down, I know we are all busy.
    A few extra minutes on the phone can save hours in the ED, ward, flight – for the patient and the receiving hospital
    We need to be smarter about logistics of transfer

    Work avoidance ultimately results in more work for somebody – maybe you !

  3. Rob Park says

    Love the article. Glad to see that it’s not just me who gets the ‘short shrift’ on the phone from our colleagues sometimes. I get foolishly upset about it and think its somehow my communication fault. But then I hear that it happens to everyone. It’s just a shame that it does! Thanks for the article, reminds me that it’s not just me!

  4. mark raines says

    Hmm, I can imagine the conversation with ED…… have you spoken with the on-call surgical registrar yet????

  5. Kelvin says

    Hi Tim
    I was on duty when your patient rocked up in the ED. Great letter and documentation by the way. Needless to say, after reading your letter I immediately put in the admission paperwork under the surgical team.

  6. Mandy Lishman says

    Sad really. There is no excuse for rudness. As an ED Physician I find that I know many of our referring GP’s and where they are calling from which gives me an advantage over the rotating often junior registrars from the “big smoke”.

    Having said that when I don’t know someone I have apologised in advance for starting with the basics as I have also had transferred a “torted testicle” after a trauma (ruptured spleen), isolated femur fracture (unstable C2) despite going through the obvious questions.

    The coroner’s case is interesting and we will discuss to see if we can improve our practice so the holes in the swiss cheese don’t line up.

    Cheers

  7. says

    Thanks Mandy

    Noone wants to ‘point the bone’ – and communication failures work BOTH ways (I have certainly sent in my fair of duff referrals).

    I reckon ISBAR helps, as does knowling each other and understanding resource limitations.

    Dumping on ED is something I am anxious to avoid – having been “dumped on” in the past!

    When younger, as the admitting registrar, i was counselled to be like the man from Del Monte (classic UK advert – “the man from Del Monte, he say ‘yes’!”

    either the GP knows what he/she is doing – in which case you need to see the patient

    or

    the GP has no idea what he/she is doing – in which case you need to see the patient

    I concur that sometimes ED is the best place for an undifferentiated patient.

    Asking questions of the referring doctor is a positive bonus…it helps us frame our thought processes, may prevent an unnecessary transfer and also is educational – more so when we know each other.

    I don;t like the ‘I am sending you the patient you have to see them’ referral – prefer an opening-up of communication between professionals.

    These sort of conversations help, I reckon.

  8. says

    Thus the conversation continues in ED.

    Me: Hello, I understand you have been referred a patient, Mr X from KI with an acute abdomen.

    Surg RMO: Have you assessed the patient?

    Me: The patient is fasted, had analgesia and fluids running. He is stable and comfortable at the moment. There is a good letter from the GP explaining everything. There is nothing else further for us to do.

    Surg RMO: But I want an ED doctor to assess the patient before I will accept the referral.

    Me: I am the ED consultant who has read the comprehensive referral letter from the GP. I have assessed that the patient is suitable to be reviewed on the ward .

    Surg RMO: I am not admitting the patient until a CT is done

    Me: There is no reason the CT has to be done whilst they are in the ED. I am putting the admission paperwork through under your team

    Surg RMO: You can’t do that.

    Me: I can and I will but if you have a problem with that I can speak directly to your consultant to see what he thinks.

    Surg RMO: Um. Ah… That isn’t necessary. I will come down and see the patient.

    Me: Don’t take too long because they will probably be on the ward by the time you get here.

  9. Chris Cole says

    Great post, Tim.

    I do, however, feel obliged to point out that you are being heinously unfair in singling out our surgical colleagues in this manner. That one of them was capable of carrying on a coherent phone conversation, of sorts, at all clearly represents significant progress on their discipline’s behalf. ;-)

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