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Enhancing Consultations in the ED

Author Information (click to view)

Chad Kessler, MD, MHPE

Section Chief, Emergency Medicine
Jesse Brown VA Hospital
Clinical Associate Professor, Departments of Emergency Medicine, Medical Education, and Internal Medicine
Associate Program Director, Combined Internal Medicine/Emergency Medicine Residency
University of Illinois-Chicago

Chad Kessler, MD, MHPE, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

Figure 2 (click to view)
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Chad Kessler, MD, MHPE (click to view)

Chad Kessler, MD, MHPE

Section Chief, Emergency Medicine
Jesse Brown VA Hospital
Clinical Associate Professor, Departments of Emergency Medicine, Medical Education, and Internal Medicine
Associate Program Director, Combined Internal Medicine/Emergency Medicine Residency
University of Illinois-Chicago

Chad Kessler, MD, MHPE, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

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Devoting more time to educating physicians on effective communication and consultation techniques and using standardized approaches may decrease overcrowding and response times while improving patient outcomes.

In EDs nationwide, consultations between emergency physicians (EPs) and other doctors or specialists for advice or intervention regarding patient care occur on a daily basis. Emergency medicine (EM) consultation is an important aspect of patient care, but few studies have analyzed the consultation process and efforts to improve communication and patient outcomes during such consultations. In most situations, consultation is not a focus of medical student or resident training, even though the importance of improving these processes is critical to patient safety and societal cost.

Recent studies have shown that communication failure appears to be at the heart of most errors when patients are transitioned from ED to inpatient settings. Some investigations estimate that poor communication occurs in 14% to 24% of inpatient consultations. These events can increase direct costs to patients, pose a financial burden on the healthcare system, and result in poorer patient care and patient satisfaction. “In all fields of medicine, it’s paramount to communicate effectively with other personnel during consultations,” explains Chad Kessler, MD, MHPE. “More efforts are needed to educate physicians and consultants on effective communication techniques.” For EDs, this may lead to improved communication between physicians, fewer resources utilized in patient care, and decreased length of ED stays.

Evaluating Consultation Processes

In the June 2012 Journal of Emergency Medicine, Dr. Kessler and colleagues had a study published that evaluated EM consultation processes by analyzing strategies used by EPs. The study also sought to create a framework for EM consultation that can be taught and learned in the ED setting. Data from EPs were collected from informal interviews, surveys, and 1-hour group interviews to further explore issues and trends. In addition, the current literature on EM consultation was comprehensively reviewed.

According to findings, the key themes identified by study respondents that were vital to successful consultations were organizational skills, interpersonal and communication skills, and medical knowledge. “Successful consults were often the result of physicians asking purposeful, focused questions,” says Dr. Kessler. “Being concise and prompt, having coherent presentations, and preparing adequately for the consultation are other important factors.”

When conflicts between EPs and consultants occurred, these events appeared to stem from receiving no response or a lack of timely responses to requests for consults, according to the study results. Conflicts were usually managed through concessions, compromise, and negotiation. Other principles for conflict management included avoiding criticism or questioning of the other doctor in front of patients, maintaining professional standards despite what the other party said or did, and actively listening to the consultant.

The Five Cs Model Adapted

There is currently no standardized framework for EM consultation, but steps can be taken to improve chances for a successful consultation. For example, a model called the “Seven Cs of Consulting” has been successful in improving consultations in business. The study by Dr. Kessler and colleagues notes that the general concepts of this model can be easily adapted to ED consultation. “We can shorten it to the Five Cs of EM Consulting,” he says (Table 1). “These five steps— contact, communication, core question, collaboration, and closing the loop—could easily be applied to all consultations in the ED and can offer consistency within the consultation process.”

Interpersonal and communication skills are a critical part of any ED consultation. Politeness, willingness to help, and clearly communicating with other consultants were key factors to having positive and successful consultations. Relational communication skills led to the development of three other critical Cs in the Five Cs model: contact, communication, and closing the loop. “These strategies and others can be easily employed to improve communication,” says Dr. Kessler (Table 2). “Communication through collaboration also represents a key medical knowledge skill.”

Standardizing Approaches for Emergency Medicine Consultations

Dr. Kessler suggests that a standardized framework be followed for every EM consult to ensure completeness. “This is a process that can be taught to learners at all medical education levels and is likely to enhance consultations. The Five Cs model is currently being tested in cohorts of EM residents, but it’s likely that more experienced physicians can also benefit from such interventions. As we gather, analyze, and interpret more data on the model as it relates to the ED, it’s hypothesized that EPs of all levels who are trained with the Five Cs model will have more successful consultations. With more validity evidence, we may finally develop the standardized framework we so desperately need.”

What steps do you take to ensure a successful consultation with other doctors?

Readings & Resources (click to view)

Kessler C, Kutka BM, Badillo C. Consultation in the emergency department: a qualitative analysis and review. J Emerg Med. 2012;42:704-711. Available at: http://www.sciencedirect.com/science/article/pii/S0736467911003714 or at http://www.medscape.com/viewarticle/766502.

Lee RS, Woods R, Bullard M, et al. Consultations in the emergency department: a systematic review of the literature. Emerg Med J. 2008;25:4-9.

Guertler AT, Cortazzo JM, Rice MM. Referral and consultation in emergency medicine practice. Acad Emerg Med. 1994;11:565-571.

Cope M. The seven Cs of consulting. London, England: Pearson Education Limited; 2000.

Reid C, Moorthy C, Forshaw K. Referral patterns: an audit into referral practice among doctors in emergency medicine. Emerg Med J. 2005;22:355-358.

Marco C, Smith CA. Conflict resolution in emergency medicine. Ann Emerg Med. 2002;40:347-349.

Kuhn W. Conflict resolution between emergency physicians and consultant physicians. Available at: www.mcg.edu/som/clerkships/EM/PracticeIssues/Conflict%20Resolution%20Between%20Emergency%20Physicians.pdf.

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