Often one of the scariest things you can do as you will most likely be speaking to a more senior colleague in an unfamiliar speciality. However, as an F1, you may well know the patient best and therefore you may be best placed to refer the patient.
- Introduce yourself and say on whose behalf you are making the referral
- Remember, you hold all the information about the patient and are therefore in the driving seat
- Use the SBAR approach and you won’t go far wrong
- Know why you are referring the patient – do you want advice, is it a specific problem that needs treating/managing or are you asking a different team to take over care
- You must always have an aim or a reason. If the aim is for someone to take over care then an explanation of why they can provide better care often works better than why you can’t look after them
- Outline the purpose of your referral early. If it is simply to document that a senior/specialist is in agreement with your plan – acknowledge it (it will go a long way)
- Have all the information to hand – name, hospital/NHS number, location, diagnosis, scan/blood results, examination findings/observations, current management and/or questions you have as a team regarding ongoing management
- Write down what you want to say if it is easier or you get nervous on the phone
e.g. Calling a paediatric haematology team
Hi, my name is Dr Potter and I am one of the doctors on ward 3 and have been asked by the consultant, Dr Granger, to refer this patient to you. Ronan is a 12yr old boy who has a suspected diagnosis of leukaemia. Hospital/NHS number is 1234. He presented with pallor and easy bruising and had hepatosplenomegaly and lymphadenopathy on examination. His Hb is 65, platelets 12 and white cells 95 with blast cells seen on the smear. He has also just spiked a temperature of 38C. We wanted to confirm management – blood cultures and start abx, blood and platelet transfusion, hyper-hydration – can we just confirm target volume; and start allopurinol? We haven’t yet spoken to parents, anything specific you want us to include in that discussion?
e.g. Calling critical care team
Hi, my name is Dr Potter and I am the F1 on Ward 3. My consultant Dr Granger has asked if you could come and review one of our patients Jenny Smith for admission to critical care. She is 36yrs old with a background of breast cancer and is receiving intensive chemotherapy. She presented with febrile neutropenia and has deteriorated overnight. She is breathlessness and requiring 60% oxygen to maintain saturations above 94%, her heart rate is 124 with BP 90/54 following a fluid challenge of 500mls normal saline. We think she now needs inotropes and more ventilator support. She is otherwise in good health and is responding well to chemotherapy.
NB: Critical care discussions should be done by a senior doctor
Both these referrals are good because they follow SBAR, stating who is calling and why. This provides the relevant background and clinical information along with expected or suggested management plan plus any clinical questions.
To illustrate the difference here are some inappropriate referrals
e.g. Calling a cardiologist
Hi, I’m Dr Potter from Ward 7. My consultant has asked I speak to you about this 58-year-old female patient with atrial fibrillation. She’s known to have osteoarthritis and she lives alone. Could you advise management?
Here we don’t have relevant background details nor do we know if this patient has known or new AF. We don’t know if the patient is unwell with this AF or otherwise (?could it be driven by a much more pressing sepsis). It does not ask a question (management of what? rate control? anticoagulation? cause? ablation?). See if you can think about how you would improve this referral.
e.g. Calling for an orthopaedic/surgical colleague to report an x-ray
Hi, I’m Dr Potter from ward 4; I’m calling on behalf of my consultant who wants you to look at an x-ray. This is a now 4 weeks old 24-weeker with abdominal distension and bilious aspirates. I don’t think there is pneumatosis or free air, although there are some non-specific distended loops. I think clinically the patient has septic ileus given their abdomen is non-tender rather than necrotising enterocolitis.
Here the person is asking a non-radiologist to report an x-ray. Either they should ask the surgical team for clinical management of a patient with suspected septic ileus with a differential including necrotising enterocolitis or the radiology team for interpretation of the x-ray.
What to do when referrals are not accepted
- Ask “Why?”. This is a powerful question as it makes the person you’re referring to reflect on their own rationale but also allows you to provide further clarification
- If there’s not enough detail, it isn’t the right specialty, further tests are needed or others then at least you have an idea of what to do next
- If the reason is “I will only discuss with a senior doctor”, do inform them that you are asking on behalf of your senior doctor and that for your learning it would be helpful to know where you are going wrong but also so you can ask them and help provide more information. Note down their details and explain to them that you will inform the consultant their rationale for not accepting the referral.
- Ask for their details & their consultant informing them that this will enable your seniors (including your consultant) to discuss this with the right people
- Discuss the above with your team
Written by Dr Helen Moore (ST7 Paediatrics)
Edited by Dr Akash Doshi (CT1)
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