Improving Communication in Improving Communication in the Emergency Department: the Emergency Department:

The 5 Cs Model of ConsultationThe 5 Cs Model of ConsultationEducational SoundbitesCORD Academic Assembly 2011San Diego , CA

Chad Kessler, MD, MHPEChad.Kessler@VA.gov

15 Minute Plan of Attack Identification of a problem Communication and consultation background What’s the big idea? The 5 Cs of Consultation Impact to the field Questions and comments

Identification of a Problem

Lack of formal training in undergraduate or graduate medical education

Background: Clinical Communication for safe patient care

Medical errors Delays in treatment and care

Hand-offs and consultations

Lack of standardized process or modelJCAHO. Sentinel Event Alert. Delays in treatment. http://www.jointcommission.org/assets/1/18/SEA_26.pdf. 2002; 26. Accessed Oct 1, 2010. Cheung DS, Kelly JJ, Beach C, et al. Improving handoffs in the emergency department. Ann Emerg Med. 2010 Feb; 55(2):171-80. Beach C, Croskerry P, Shapiro M. Profiles in Patient Safety: Emergency Care Transitions. Acad Emerg Med. 2003; 10(4):364-367.

Education: ACGME Core Competencies

Patient Care Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-Based Practice

ACGME: Outcome Project, General Competencies. http://www.acgme.org/outcome/comp/compmin.asp. Accessed Sep 15, 2010.

What’s the Big Idea?

Qualitative analysis of consultation Monster literature search

Kessler C, Kutka B, Badillo C. Consultation in the Emergency Department: A Qualitative Analysis and Review of the Consultative Process. In Press. The Journal of Emergency Medicine.

Data from Study: Skills for successful Consultation

Theme Sub-themesNumber of

CommentsClassic Example

Organizational Skills 1) Focused questions and

answers

2) Concise and coherent

presentations

3) Promptness

4) Adequate preparation

41 (43%) “…knowing specifically what you

want from a consultant as well as

anticipating what they will need to

give their assessment, speaking

briefly and getting to the point

quickly.”

Interpersonal and

Communication Skills

1) Politeness

2) Willingness to help

3) Clear communication

26 (27%) “…prompt, pleasant and treated us

as equals.”

Medical Knowledge 1) Accurate history

2) Investigating the problem

3) Ownership of patient

28 (30%) Taking “ownership of the patient.”

5 Cs Checklist AssessmentFive C’s Checklist Item Done Not DoneContact Introduction of consulting and consultant physicians. Building of relationship.

- States name- States rank and service- Identifies supervising attending- Identifies name of consultant physician

____________________

____________________

Communicate Give a concise story and ask focused questions.

- Presents a concise story- Presents an accurate recount of information/case detail- Speaks clearly

_______________

_______________

Core Question Have a specific question or request of the consultant. Decide on reasonable timeframe for consultation.

- Specifies need for consultation- Specifies timeframe for consultation

__________

__________

Collaboration A result of the discussion between the ED physician and the consultant, including any alteration of management or testing

- Is open to and incorporates consultant’s recommendations

_____ _____

Closing the LoopEnsure that both parties are on the same page regarding the plan and maintain proper communication about any changes in the patient’s status.

- Reviews and repeats patient care plan- Thanks consultant for consultation

__________

__________

Reliability Inter-item reliability of GRS (Chronbach’s alpha)

Rater 1 0.9 Rater 2 0.89 Rater 3 0.87

Inter-rater reliability for GRS 0.71 Inter-rater reliability for checklist 0.94 Correlation (pearson) between GRS and checklist

(n=43, p<0.0001) Surgery cases r=0.59 Psychiatry cases r=0.71

Main Results

Intervention group had significantly higher GRS scores (4.1 vs. 3.5, F(1,39)=33.5, p<0.0001) and Checklist Scores (10.7 vs. 7.0, F(1,39)=196, p<0.0001).

No natural progression in consulting skills with increasing PGY level

Impact to the Field

An effective, standardized model of consultation; the 5 Cs

Assessment of difficult to measure/quantify ACGME core competencies

Wide-spread education for under-graduate and graduate medical learners

Stepping it Up From simulated setting to clinical setting Demonstrate improvement in process

measures and patient outcomes Improve communication and relationships Improve patient safety Decrease resource utilization

Electronic Medical Records Beyond Emergency Medicine

Sug/quest/ments