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
15 Minute Plan of Attack
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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
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Communication for safe patient care
 Medical errors
 Delays in treatment and care
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Hand-offs and consultations
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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.
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
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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
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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
Number of
Theme
Sub-themes
Comments
Classic Example
Organizational Skills
1) Focused questions and
41 (43%)
“…knowing specifically what you
answers
want from a consultant as well as
2) Concise and coherent
anticipating what they will need to
presentations
give their assessment, speaking
3) Promptness
briefly and getting to the point
4) Adequate preparation
quickly.”
Interpersonal and
1) Politeness
Communication Skills
2) Willingness to help
26 (27%)
“…prompt, pleasant and treated us
as equals.”
3) Clear communication
Medical Knowledge
1) Accurate history
2) Investigating the problem
3) Ownership of patient
28 (30%)
Taking “ownership of the patient.”
5 Cs Checklist Assessment
Five C’s
Contact
Introduction of consulting and
consultant physicians. Building of
relationship.
Checklist Item
- States name
- States rank and service
- Identifies supervising attending
- Identifies name of consultant physician
Done
_____
_____
_____
_____
Not Done
_____
_____
_____
_____
Communicate
- Presents a concise story
Give a concise story and ask focused - Presents an accurate recount of
questions.
information/case detail
- Speaks clearly
_____
_____
_____
_____
_____
_____
Core Question
- Specifies need for consultation
Have a specific question or request - Specifies timeframe for consultation
of the consultant. Decide on
reasonable timeframe for
consultation.
_____
_____
_____
_____
Collaboration
- Is open to and incorporates consultant’s
A result of the discussion between recommendations
the ED physician and the
consultant, including any alteration
of management or testing
_____
_____
Closing the Loop
- Reviews and repeats patient care plan
Ensure that both parties are on the - Thanks consultant for consultation
same page regarding the plan and
maintain proper communication
about any changes in the patient’s
status.
_____
_____
_____
_____
Reliability
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Inter-item reliability of GRS (Chronbach’s alpha)
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Rater 1
Rater 2
Rater 3
0.9
0.89
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)
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Surgery cases
Psychiatry cases
r=0.59
r=0.71
Main Results
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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).
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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 undergraduate and graduate medical learners
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Stepping it Up
From simulated setting to clinical setting
 Demonstrate improvement in process
measures and patient outcomes
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Improve communication and relationships
 Improve patient safety
 Decrease resource utilization
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Electronic Medical Records
 Beyond Emergency Medicine
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Sug/quest/ments