I am sending you to the ED!-Reflections on how to refer to Children’s ED

Mike Greenwald, Pediatric Emergency Medicine Physician

CME 1.0 credit available complete after reading all 3 articles-Link at the end !

Those of us who practiced medicine in the previous century (“OK Boomer” – there, I said it) can tell our younger colleagues stories about the limitations we used to face in treating sick and injured children.  We recall a time before we had eradicated some deadly diseases with vaccines, before we had pediatric specific approaches to trauma and many medical diseases and before we developed so many ready options for imaging and other studies.  Yes, 2019 doctors struggle with different challenges.  We all still work very hard.  EMR has solved some problems and created others.  Perhaps just as challenging – we are not quite as tight nit a medical community compared to when we were smaller.  We rely on a growing number of often unfamiliar colleagues to help care for children in our community.  That distance naturally leads to challenges and even barriers in communication and collaboration.

So this article is an attempt to share some issues from one side of a relationship.  We asked faculty in our group to answer the question: “What do you wish referring primary care providers would better understand to improve the care we deliver to our patients?” Like any survey – this one has limitations.   We recall negative experiences more vividly than positive ones.  The truth is that the vast majority of referrals we get are clear, appropriate and helpful.  What follows is a summary of observations of what might make a more effective transition of care.  Perhaps none of these apply to you – but we hope that at least some of what you read here makes sense and you find useful.  As always – we welcome your feedback and on-going collaboration with us so we can improve our role in helping care for your patients.

  • Be explicit in your concern.   The families sent in to see us often assume that we have comprehensive knowledge of their medical issues.  They may bring with them a brief note with vague information or simply neglect to tell us that you sent them in.  Like a game of telephone the details can easily change. 

What exactly is the purpose of this referral? If your concern is based on test results please share those details – especially growth chart data for the failure to thrive concern and lab or radiology results outside the CHOA system. Be clear in your call in whether you want a call back and provide the best contact number possible (ideally a direct #).  If you haven’t heard from us please don’t hesitate to call the transfer center to speak with the treating physician.  We may have every intention of calling you as requested but neglect to do so in the flurry of a busy shift.

  • Use the Transfer Center (404-785-7778). When you call in a patient you have the option to simply leave a message or to speak with one of us. Either way – your call in information is recorded in the chart and highlighted by the patient’s name with a letter “C” next to their name.  This reminder is intended to guide us to your note.

We understand that you are busy and sometimes it takes more time than we’d like to speak with someone in the transfer center.  Like the ED volumes – the transfer center calls can vary dramatically.  In fact – the CHOA Transfer Center is the busiest Pediatric Hospital Transfer Center in the Country!  It is staffed with 1-5 nurses at a time 24/7 based on volume patterns – with plans to increase staffing with our up coming move at the North Druid Hills campus. In addition, they are actively working on new ways to streamline the process. 

  • We want to speak with you!  We often get patients with a concern that could have been addressed with a conversation on the phone with either an ED doc or other sub specialist.  Some of the patients could have been a direct admission; others would eventually be sent to a specialty clinic. Not sure if ED referral is the best option for this patient? Call us! The Transfer Center can facilitate this – typically in less than 15 minutes.  

Please understand when you are waiting to speak with us the Transfer Center nurse is diligently requesting us to answer the call.  Your wait is only because we a caring for patients; but when we are at a desk charting we will stop and pick up the phone. We would much rather spend 5 minutes chatting with you about your concerns rather than explain to your patient why we can’t do what was expected when they finally get into a room after a long wait.

  • Sign out patient info to your on call colleague.  It seems to be a common occurrence that when we call a practice after hours the on call doc knows nothing about the patient sent in by their colleague. That can make our evaluation more challenging than necessary.  A brief sign out can go a long way to ensure accurate communication and effective follow-up.
  • Be clear and careful regarding expectations.  You might be surprised at how often we get a family who says they were told they would see a subspecialist in the ED or get a specific study performed.  (Yes, we know that they may have distorted what you told them).  We don’t dispense nebulizers and seldom can get an MRI.  While we can speak by phone with our subspecialty colleagues, it is simply not feasible (nor necessary) for them to see each patient presenting in the ED.  Also, we try to follow guidelines to reduce unnecessary testing so head injured patients may be assessed clinically without imaging and children with flu-like illnesses may be diagnosed clinically rather than with a flu test.

If you have an urgent question for a specific sub specialist consider using the transfer center to speak with them.   Contact radiology if you want to expedite or ask about a specific imaging study.  Like the surgeon who evaluates abdominal pain or the cardiologist who assesses a murmur, the ED physician will choose tests and treatments for patients based on their training and experience. 

  • Be judicious about sending in contagious or vulnerable patients such as neonates.  This is particularly important this time of year when the waiting room may be filled with children experiencing influenza.  Each year it seems we get a surge of flu positive patients who were recently seen in our ED for an unrelated problem.  They may have presented without the flu but left with it!  Also in that waiting room are neonates and immuno-compromised children.  If you are concerned about a dangerous infection such as TB or Measles – lets talk before sending in the patient!

CLICK on Link below to receive CME Credit after reading all 3 articles!!!!

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