Making referrals to in patient teams is one of the most challenging aspects of working in the Emergency Department. Every call you make generates work for your colleagues, who may already be dealing with multiple calls and patients and may be in theatre or the out patient clinic. Without proper preparation instead of being a simple one way delivery of information it can turn into an impromptu viva examination.

Referral - an example of what can go wrong

Here the SHO has made a few errors resulting in the specialist avoiding the referral and leaving the patient inappropriately in the ED.
1, Don't ask in patient specialities for "advice". Immediately they will think that by giving advice they can avoid the referral and thereby avoid seeing the patient.
2, Don't let yourself be interupted. If you have prepared a concise referral with only the pertinent details it should keep the attention and not take long.
3, Do not accept being fobbed off with advice to do further tests or keep the patient in the ED. The decision to admit is generally a clinical one and testing rarely makes a difference to whether the patient comes in or goes home.

Referral - how to make it easier
Before calling it is vital that you are clear on the purposes of your call - which will almost always be a referral for admission. Remember, if you need advice that is what your Consultant and Registrar colleagues in the ED are for. When starting out it is worth just running over the reason for your referral so you can anticipate any questions and hone down the content to just the things the person to whom you are referring needs to know. It is vital that for your own sanity and the patients well being the referral does not become a viva on your clinical knowledge, so prepare in advance.

The SBAR Way
At Southampton use the SBAR mneumonic to frame our referrals. This gives a format to these conversations and outlines the content of the referral
S- Situation - Identify yourself, your patient and why you are calling-
"Hi, This is Iain Beardsell one of the ED Doctors and I want to refer a 39 year called Jane Smith who I believe has appendicitis."
B - Background - Give some more details about the patient-
"She has had 24 hours of worsening right illiac fossa pain, with nausea, anorexia and three episodes of vomiting. She is previously fit and well and has no other relevant history."
A - Assessment - Outline your assessment-
"On examination she is tender in the right illiac fossa. Her urine dipstick is negative and her blood tests are awaited."
R - Recommendations - Say what you believe needs to happen next-
"I would be most grateful if you could review her and assess whether she needs further observation or a operation. I have requested a bed on the surgical ward."

Tips on referring
1, Never, ever lie or try to "sell" a patient. If you feel you have to do this ask yourself does the patient really need to be admitted or is there something else you could be doing in the ED? Also, word soon gets round if you are not telling the truth about patients and that important trust between you and the inpatient team is lost.
2, Practice your referral in your head - Does it make sense? Is the reasoning clear? Are there any questions you might be asked that you cannot answer?
3, Introduce yourself with your name, not just your designation and try to refer to the inpatient specialist by their name. By personalising the process it is much harder for someone to be rude to you and dismiss your request.
4, You are referring the patient. Very, very rarely will you be "asking for advice". Your expected outcome is admission not further work up in the ED/CDU.
5, Try to get to know the inpatient teams (see 2 above) and show an interest in your patient's outcome. Try to call them later in the shift to find out how your patient did - not only does they help your learning, but shows the in patient specialist that you were interested in your patient having the best and most appropriate care, not just how you could shift them from the ED and forget about them
6, Remember that colleagues can be very busy. You may have just interupted their lunch - no wonder they can get grumpy. Try and be understanding whilst being assertive.
7, Finish your referral with your voice going down in pitch - suggesting the end of the conversation, rather than rising - suggesting you are asking a question and opening up an unwanted viva opportunity.
8, Show "Grace Under Pressure". Never, ever get into an argument about a patient - as soon as you raise your voice you have lost the moral high ground. If you are having real trouble inform the inpatient specialist (politely) that you are going to talk to your Consultant/Registrar to confirm the referral was appropriate and that you will call them back

An example of an SBAR Referral

Admittedly this illustration is a straightforward case, but using the same methodology for all your referrals should make this aspect of working in the ED easier.