1. Improving Communication in the Emergency Department: The 5 Cs Model of Consultation Educational Soundbites CORD Academic Assembly 2011 San Diego, CA Chad Kessler, MD, MHPE Chad.Kessler@VA.gov

2. 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

3. Identification of a Problem Lack of formal training in undergraduate or graduate medical education

4. Background: Clinical Communication for safe patient care Medical errors Delays in treatment and care Hand-offs and consultations Lack of standardized process or model JCAHO. Sentinel Event Alert. Delays in treatment. http://www.jointcommission.org/assets/1/18/SEA_26.pdf. 2002; 26. Accessed Oct 1, 2010.http://www.jointcommission.org/assets/1/18/SEA_26.pdf 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.

5. 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. http://www.acgme.org/outcome/comp/compmin.asp

6. 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.

7. Data from Study: Skills for successful Consultation ThemeSub-themes Number 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 Knowledge1) Accurate history 2) Investigating the problem 3) Ownership of patient 28 (30%)Taking “ownership of the patient.”

8. 5 Cs Checklist Assessment Five C’sChecklist ItemDoneNot Done Contact 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 Loop Ensure 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 _____

11. Reliability Inter-item reliability of GRS (Chronbach’s alpha) Rater 1 0.9 Rater 20.89 Rater 30.87 Inter-rater reliability for GRS0.71 Inter-rater reliability for checklist0.94 Correlation (pearson) between GRS and checklist (n=43, p<0.0001) Surgery cases r=0.59 Psychiatry cases r=0.71

12. 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

13. 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

14. 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

15. Sug/quest/ments