OBJECTIVES:

To increase the number of essential consult elements (ECEs) included in initial inpatient consultation requests between pediatric residents and fellows through implementation of a novel consult communication tool.

METHODS:

Literature review and previous needs assessment of pediatric residents and fellows were used to identify 4 specific ECEs. From February to June 2018, fellows audited verbal consult requests at a medium-sized, quaternary care children’s hospital to determine the baseline percentage of ECE components within consults. A novel consult communication tool containing all ECEs was then developed by using a modified situation-background-assessment-recommendation (SBAR) format. The SBAR tool was implemented over 3 plan-do-study-act cycles. Adherence to SBAR, inclusion of ECEs, and consult question clarity were tracked via audits of consult requests. A pre- and postintervention survey of residents and fellows was used to examine perceived miscommunication and patient care errors and overall satisfaction.

RESULTS:

The median percentage of consults containing ≥3 ECEs increased from 50% preintervention to 100% postintervention with consult question clarity increasing from 52% to 92% (P < .001). Overall perception of consult miscommunication frequency decreased (52% vs 18%; P < .01), although there was no significant change in resident- or fellow-reported patient errors. SBAR maintained residents’ already high consult satisfaction (96% vs 92%; P = .39) and increased fellows’ consult satisfaction (51% vs 91%; P < .001).

CONCLUSIONS:

Implementation of a standardized consult communication tool resulted in increased inclusion of ECEs. Use of the tool led to greater consult question clarity, decreased perceived miscommunication, and improved overall consult satisfaction.

Ineffective communication within the health care setting leads to patient harm and medical error.13  The Joint Commission reports miscommunication as the leading cause of sentinel events in medicine.4  Communication around consultations is particularly vulnerable to error because of lack of standardization and wide communication variation among providers.5,6  At most teaching hospitals, the majority of consultation communication occurs between residents and subspecialty fellows. However, medical trainees across specialties often lack formal education on effective consult communication.7,8 

Using a survey of pediatric residents and fellows at our children’s hospital, we found 98% of residents and 96% of fellows report some degree of miscommunication during the inpatient consultation process, contributing to patient errors and near-miss events. Pediatric residents and fellows participated in focus groups to identify root causes of poor consult communication as well as possible countermeasures to optimize communication. Both groups of trainees attested to wide variation in information included within initial consult requests, which inhibits the creation of a shared mental model between providers. This leads to miscommunication, ineffective teaching and/or learning, and events that may jeopardize patient safety.9 

The main countermeasure identified through the focus groups and emphasized in consultation literature7,9,10  is standardization of the initial consult request. To create this standardized framework, 4 essential consult elements (ECEs) were identified from the focus group discussions: (1) the urgency of the consult; (2) a specific, upfront consult question; (3) a brief description of patient background; and (4) a differential diagnosis with a proposed plan.9 

The primary aim of this quality improvement (QI) project was to improve communication around initial consultation requests from pediatric residents in the inpatient setting by increasing the percentage of consults containing ≥3 ECEs from 50% to 67% over the course of an academic year, ending June 2019. Secondary outcomes included the impact of improving initial consult communication on consult question clarity, perceived miscommunication, patient errors, and satisfaction with the consultation process.

We conducted this study at a medium-sized (350+ bed) quaternary care children’s hospital in Northern California providing care in >150 subspecialties. The institution is the primary training site for 100 pediatric residents and 120 subspecialty pediatric fellows. Communication between residents and fellows occurred primarily via pager and telephone at the onset of the project before any interventions. No formal education, curricula, or standard for consult communication existed. These factors formed the rationale for the provider groups and setting we targeted for intervention. The Institutional Review Board at Stanford University reviewed this project and determined it to be exempt.

Our project team included members from the Pediatric Fellows’ QI Council, which was composed of 10 pediatric fellows, representing 6 different subspecialties, and a supervising faculty mentor (N.S.S.). We engaged key stakeholders, including pediatric residents and fellows, residency and fellowship leadership, faculty within subspecialty divisions with high inpatient consult volume, and clinical informaticists.

The current state of consult communication was assessed with surveys of pediatric residents and fellows, real-time audits of initial consult communication by fellows (Supplemental Fig 9), and the previously mentioned focus group–based qualitative study.9  On the basis of our current state analysis, we developed key drivers of consult communication variation (Fig 1) to identify areas for targeted improvement.11 

FIGURE 1

Key driver diagram used to identify primary and secondary drivers of variation in consultation communication. EMR, electronic medical record.

FIGURE 1

Key driver diagram used to identify primary and secondary drivers of variation in consultation communication. EMR, electronic medical record.

Close modal

After identifying key drivers, we used the framework of the validated health professional teamwork model, TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety),12  along with our local findings to develop specific interventions. A standardized consultation tool during the initial consult request effectively targeted all drivers. We incorporated ECEs into situation-background-assessment-recommendation (SBAR), a well-validated communication tool used throughout the health care setting (Fig 2). SBAR has been shown to decrease miscommunication, improve patient safety, and level the medical hierarchy.2,1315  SBAR was chosen as the backbone of our standardized tool given its existing use by pediatric residents during rapid responses and/or code events for effective transfer of pertinent information. The modified SBAR places the consult question and urgency upfront within “situation” to emphasize its importance and helps frame the story as the consultant listens to the remaining information. “Background” includes the pertinent and brief history related to the patient and consult question. Finally, consultees are asked to pose their differential diagnosis and next steps under “assessment” and “recommendation” to promote learner and resident clinical reasoning and autonomy while allowing consultants to quickly identify areas for targeted teaching.

FIGURE 2

Novel standardized framework for initial consultation request that includes all ECEs using SBAR communication framework.

FIGURE 2

Novel standardized framework for initial consultation request that includes all ECEs using SBAR communication framework.

Close modal

After developing the novel SBAR tool, we used the Institute for Healthcare Improvement’s Model for Improvement16  to guide implementation of our tool. We planned iterative interventions and analyzed our performance over time using multiple plan-do-study-act (PDSA) cycles.

We present our improvement activities organized as 3 PDSA cycles.

PDSA Cycle 1

The first cycle was focused on raising awareness of the scope of the problem around consult communication and providing education on the SBAR communication tool. We developed a bundle of interventions for widespread dissemination of the tool, including an educational and multimedia campaign deployed between July and August 2018, coinciding with the onboarding of new residents and fellows.

The educational intervention consisted of the creation and delivery of 30- to 90-minute interactive workshops to teach the SBAR consult tool to all pediatric residents at scheduled morning reports, noon conferences, and intern orientation. The workshop consisted of a brief didactic session including instructional videos followed by breakout sessions in which residents used mock consult requests and role-play to practice and receive feedback using the SBAR tool. Subspecialty fellows received SBAR education at fellows’ orientation and Fellows’ QI Council meetings (monthly meetings involving fellows from each subspecialty in hospital-wide initiatives) and through a series of project update e-mails. Finally, we deployed a hospital-wide multimedia campaign to provide awareness and reminders for residents, fellows, and the broader hospital community. This included posting flyers in all physician workrooms, displaying hospital-wide screensavers, and distributing SBAR badge cards to residents (Fig 3A) and fellows (Fig 3B) for point-of-care access to the SBAR framework.

FIGURE 3

Created interventional material. A, Badge cards printed and laminated for all pediatric resident and fellows. B, Fellow expectations printed as a sticker and placed into a planner distributed to all fellows. C, New EHR order incorporating components of SBAR into a generated text page. ASAP, as soon as possible; CNS, central nervous system; CSF, cerebrospinal fluid; CTX, ceftriaxone; cx, culture; ED, emergency department; HSV, herpes simplex virus; ICN, intermediate care nursery; Inst., instruction; LP, lumbar puncture; MR, medical record; Vanc, vancomycin.

FIGURE 3

Created interventional material. A, Badge cards printed and laminated for all pediatric resident and fellows. B, Fellow expectations printed as a sticker and placed into a planner distributed to all fellows. C, New EHR order incorporating components of SBAR into a generated text page. ASAP, as soon as possible; CNS, central nervous system; CSF, cerebrospinal fluid; CTX, ceftriaxone; cx, culture; ED, emergency department; HSV, herpes simplex virus; ICN, intermediate care nursery; Inst., instruction; LP, lumbar puncture; MR, medical record; Vanc, vancomycin.

Close modal

PDSA Cycle 2

In October 2018, after implementation of the initial education and multimedia bundle, our project team met with residents and fellows to understand prevailing barriers to the use of SBAR. These included lack of attending-level support and perceived difficulty by residents in completing SBAR without interruption from fellows. To increase faculty support for SBAR, we gave presentations at subspecialty division meetings to foster engagement and share how it could address existing communication gaps. Divisions that frequently requested and/or performed consultations were targeted. To address the issue of fellows interrupting residents during SBAR consult requests, we expanded our educational intervention from a “push” to a “push-pull” model to encourage fellows to actively participate and reinforce resident use of SBAR.17,18  To accomplish this, we asked fellows to prompt residents to produce any missing components of SBAR during their verbal consultation request.

PDSA Cycle 3

In January 2019, with analysis of real-time audits, we found that some residents were not consistently using SBAR, and consult urgency was the most often missed ECE. Our third cycle was aimed at reengaging resident awareness and integrating ECEs into resident standard workflow. We began sending reminder e-mails to all residents and fellows rotating onto an inpatient service. For a higher-reliability intervention to aid in sustainability, we also developed a new consult order within our electronic health record (EHR), Epic (Epic Systems Corporation, Verona, WI). The order includes consult urgency and specific patient information (extracted electronically from the patient’s chart and from manual input). After signing this order, the on-call fellow is directly paged, eliminating the resident’s need to manually identify and page the fellow to request the consult. A reminder to use SBAR during the verbal consultation request is also included in the order (Fig 3C).

Outcome measures were collected through real-time consult audits and pre- and postintervention surveys. Real-time consult audits were collected by fellows in 7 different subspecialties. To promote interrater reliability of consult audits, each fellow was sent the same instructional e-mail and received verbal training from 1 author (S.P.). We did not perform a formal interrater reliability assessment because the real-time nature of these consults prevented multiple fellows from auditing the same consult request. Audit questions with subjective answers were given discrete qualifiers to help mitigate bias. For example, consult question clarity was based on the number of clarifying questions required to understand the consult question (very well articulated = no clarifying questions, well articulated = 1 clarifying question, somewhat well articulated = 2 clarifying questions, etc).

Pre- and postintervention surveys were collected over a 1-month period in May 2018 and February 2019. Residents and fellows received 2 reminder e-mails about survey completion. We developed the surveys by expert consensus to assess all study outcomes, piloted them with a group of 6 residents and 3 fellows, and made minor modifications before distribution.

Outcome Measures

The primary outcome measure was the percentage of verbal consult requests containing ≥3 ECEs, measured serially over time by using consult audit groups of 6. Only consultations requested by pediatric residents were included. Secondary outcomes included consult question clarity (measured through real-time audits), perceived patient safety errors, and miscommunication (assessed by using pre- and postintervention surveys).

Process Measure

Percentage of consult requests using the SBAR format was chosen to understand adherence to the tool. This was evaluated through real-time consult audits and reported as SBAR not used, SBAR used but incorrectly (incorrect order or missing 1 component), or SBAR used correctly.

Balancing Measure

By asking residents and fellows to adhere to a standardized format, we sought to ensure that this did not create untoward consequences that would impact their satisfaction and, over time, hinder use of the tool. Resident satisfaction was gathered by using the pre- and postintervention surveys, and fellow satisfaction was gathered during real-time audits of consult requests.

Run charts were used to analyze the primary outcome measure, percentage of consults containing ≥3 ECEs within initial consult requests, as well as the process measure.19  With a total of 184 audits completed, percentage of consults was calculated over 6 audits serially resulting in 31 discrete observation groups.

Run charts were reviewed at regular project meetings. Signal of change was determined by using established run chart rules.19  This allowed us to continuously assess the effect of our interventions and determine if and when nonrandom attributable change occurred. Surveys were collected pre- and postintervention with Likert-scale responses grouped into proportions that were compared by a χ2 test to assess for statistical differences by using Prism by GraphPad.

Fifty-four consult requests were audited preintervention between February and June 2018 versus 130 requests audited postintervention between July 2018 and July 2019, representing a convenience sample of 8% of all inpatient consults during this time period. All pediatric subspecialty fellows, excluding ICU fellows, were asked to voluntarily complete audits. Twenty pediatric fellows representing 7 different subspecialties participated. Limitations to the total number of consults audited included the decreased frequency of service time for fellow auditors who were in their second or third year of training and lack of fellow incentives to complete audits. The demographics of pediatric residents and fellows completing pre- and postintervention surveys are detailed in Table 1. Preintervention, 57 (65%) pediatric residents and 46 (59%) pediatric fellows completed the survey versus 62 (70%) and 55 (71%) postintervention. Residents and fellows from all postgraduate year (PGY) levels were represented as were fellows from 12 different subspecialties.

TABLE 1

Demographics of Pediatric Residents and Fellows Responding to Pre- and Postintervention Surveys

PopulationPreinterventionPostintervention
Total, n (%),   
 Residents 57 (65) 62 (70) 
 Fellowsa 46 (59) 55 (71) 
Sex, n (%)   
 Resident   
  Female 46 (81) 42 (68) 
  Male 6 (10) 15 (24) 
  Declined to answer 5 (9) 5 (8) 
 Fellow   
  Female 28 (61) 28 (51) 
  Male 10 (22) 13 (24) 
  Declined to answer 8 (17) 14 (25) 
Level of training   
 Resident, n   
  PGY1 18 21 
  PGY2 17 19 
  PGY3-5 17 17 
 Fellow, n   
  PGY3 
  PGY4 10 19 
  PGY5 14 17 
  PGY6+ 13 
  Unspecified 
PopulationPreinterventionPostintervention
Total, n (%),   
 Residents 57 (65) 62 (70) 
 Fellowsa 46 (59) 55 (71) 
Sex, n (%)   
 Resident   
  Female 46 (81) 42 (68) 
  Male 6 (10) 15 (24) 
  Declined to answer 5 (9) 5 (8) 
 Fellow   
  Female 28 (61) 28 (51) 
  Male 10 (22) 13 (24) 
  Declined to answer 8 (17) 14 (25) 
Level of training   
 Resident, n   
  PGY1 18 21 
  PGY2 17 19 
  PGY3-5 17 17 
 Fellow, n   
  PGY3 
  PGY4 10 19 
  PGY5 14 17 
  PGY6+ 13 
  Unspecified 
a

Pediatric subspecialties included rheumatology, pulmonology, nephrology, neurology, infectious diseases, hematology-oncology, gastroenterology, endocrinology, intensive care, cardiology, allergy and immunology, adolescent medicine, and genetics.

The percentage of consults containing ≥3 ECEs increased after a series of interventions, from 50% to 100% (Fig 4). The first shift occurred during PDSA cycle 2 by promoting SBAR among faculty and asking fellows to provide feedback to residents on SBAR use during their audits and resulted in a median of 67%. Integrating SBAR into the EHR (PDSA cycle 3) led to a second shift and final median of 100%. During this final phase of the project, 73% (29 of 40) of consults contained all 4 ECEs compared with 9% of consults (5 of 54) before any intervention (P < .001).

FIGURE 4

Primary outcome measure represented by a run chart revealing the percentage of consults containing ≥3 ECEs over the study period. EMR, electronic medical record.

FIGURE 4

Primary outcome measure represented by a run chart revealing the percentage of consults containing ≥3 ECEs over the study period. EMR, electronic medical record.

Close modal

Before the interventions, 52% (n = 28) of consult questions were rated as either well articulated or very well articulated. Postintervention, this increased to 77% (n = 99) (P < .001) for all audited consults and 92% (n = 96) among consult requests using SBAR (Fig 5).

FIGURE 5

Consult question clarity collected through real-time consultation audits collected by fellows based on a 4-point Likert scale.

FIGURE 5

Consult question clarity collected through real-time consultation audits collected by fellows based on a 4-point Likert scale.

Close modal

Perceived frequency of miscommunication during the initial consultation request was assessed on a 5-point Likert scale. Fellows noted less frequent miscommunication (miscommunication occurring more than half the time) after implementation of the tool (53% vs 17%; P < .001) (Fig 6A). Reported overall miscommunication did not improve after implementation of SBAR among residents (Fig 6B). However, residents who used SBAR ≥50% of the time reported significantly less frequent miscommunication compared with those who used SBAR <50% of the time (69% vs 31%; P = .01) (Fig 6C). Perceived types of patient safety errors were assessed by asking trainees to report any errors that occurred because of consultation miscommunication within the last 3 months. The most commonly reported errors did not significantly change postintervention: incorrect laboratory orders (residents 20% vs 18%; fellows 17% vs 13%), laboratories drawn (residents 17% vs 14%; fellows 16% vs 16%), imaging ordered (residents 4% vs 14%; fellows 10% vs 7%), follow-up plan (residents 22% vs 26%; fellows 16% vs 17%), and delivered diagnosis (residents 2% vs 9%; fellows 13% vs 9%).

FIGURE 6

Miscommunication secondary outcome. A, Fellow-perceived consult miscommunication pre- and postintervention based on a 5-point Likert scale. B, Resident-perceived pre- and postintervention consult miscommunication. C, Resident-perceived consult miscommunication based on SBAR usage.

FIGURE 6

Miscommunication secondary outcome. A, Fellow-perceived consult miscommunication pre- and postintervention based on a 5-point Likert scale. B, Resident-perceived pre- and postintervention consult miscommunication. C, Resident-perceived consult miscommunication based on SBAR usage.

Close modal

In the postintervention period, SBAR in any format was used 83% of the time. There was a rapid shift seen in the first PDSA cycle that was sustained throughout the study period (Fig 7).

FIGURE 7

Run chart used to evaluate the process measure, percentage of consult audits using any SBAR. EMR, electronic medical record.

FIGURE 7

Run chart used to evaluate the process measure, percentage of consult audits using any SBAR. EMR, electronic medical record.

Close modal

Residents’ high level of satisfaction did not significantly change postintervention (96% vs 92%; P = .39) whereas there was significant improvement in fellow-reported satisfaction (“very satisfied” or “satisfied”) from 51% to 91% (P < .001) (Fig 8).

FIGURE 8

Balancing measure. A, Pre- and postintervention resident satisfaction of consultation communication. B, Pre- and postintervention fellow satisfaction of consultation communication.

FIGURE 8

Balancing measure. A, Pre- and postintervention resident satisfaction of consultation communication. B, Pre- and postintervention fellow satisfaction of consultation communication.

Close modal

Effective inpatient consultation requires efficient and accurate communication. Miscommunication during the initial consultation request can lead to errors that jeopardize patient care and safety as well as provider dissatisfaction. In this single-center, multiyear study, we demonstrate that implementation of a novel modified SBAR tool to standardize initial consultation communication not only sustainably increased the inclusion of ECEs but also improved consult question clarity, perceived communication, and overall consult satisfaction. Specific types of reported patient errors due to consult miscommunication did not change.

The call to standardize communication between physicians during inpatient consultations is not new.3,6,20  In emergency medicine, the 5Cs of Consultation (contact, communicate, core question, collaborate, and close the loop) revealed an increase in medical student comfort in requesting consultations21  and higher scores on third-party assessments of emergency medicine resident consult requests.22  Notably, barriers to implementing this process included the introduction of a tool unfamiliar to most trainees. The CONSULT (contact, orient, narrow question, story, urgency, later, thank you) card has also been proposed as a standardized consult communication tool among adult providers.10  However, this framework’s implementation and feasibility have not been evaluated. To our knowledge, ours is the first study in which authors examine the application of a consult communication tool in real time to improve consult communication between pediatric resident and fellows.

In this study, several local factors facilitated the success of our interventions. In our study, we used findings from a rigorous qualitative study that determined the current state of consultation interactions and allowed for the formation of resident- and fellow-driven interventions.9  From these data, we created a novel application of the existing, well-known SBAR framework within our institution that helped with the adaptability and sustainability of the intervention. In this fellow-driven project, we received significant support from both residency and fellowship leadership and leveraged an existing formalized structure for organizing fellows, the Fellows’ QI Council, which empowered QI work and encompassed multiple pediatric subspecialties. The sustainability of this intervention has been addressed by incorporating the SBAR tool into the pediatric residency’s annual bootcamp and fellowship core curriculum as well as in our EHR.

Our project has several limitations. We conducted our study at a single center that had already incorporated SBAR into its culture of standardized communication, potentially limiting generalizability to other institutions. There was also the potential for recall and sampling bias when residents and fellows completed the pre- and postsurveys. We attempted to minimize sampling bias by performing real-time audits of the ECEs and diminish recall bias by having both residents and fellows complete survey assessments only if they had been on an inpatient rotation in the previous 3 months. The relatively low percentage of total consults audited may contribute to sampling bias and over- or underestimate the percentage of consults containing ECEs. The scope of the impact of the intervention was limited to the interactions between pediatric residents and fellows. We did not include other providers such as medical students, advanced practitioners, and faculty members who are frequently involved in the hospital consultation process because of practice variability across these groups that would have been difficult to control for in the current study. Although we were able to study our intervention over the period of an academic year, we were unable to collect data over multiple resident classes because of resource limitations.

The standardized SBAR tool improved adherence to essential elements that are critical to all consultation requests. It has improved communication and increased satisfaction around inpatient consultations at our institution. This change in practice has the potential to decrease common communication failures between medical providers in the inpatient setting and positively affect patient care. Because SBAR is a widely used, simple mnemonic implemented with low-resource interventions, implementation at other institutions is feasible. We plan to expand our interventions to medical students, advanced practitioners, and faculty to standardize consult communication across the hospital. In future studies, researchers should confirm continued sustainability of the SBAR tool within the health care system. Furthermore, it will be important to examine how this standardized consult communication tool can directly impact patient safety, decrease medical errors, and improve patient-centered outcomes related to the consultation process.

Through pediatric resident, fellow, and faculty engagement and integration within the EHR, we successfully enhanced inpatient consult communication by implementing a novel standardized tool using QI methodology. This increased the percentage of consults containing ≥3 ECEs within initial consult requests and improved consult question clarity, perceived communication, and overall consult satisfaction. The SBAR tool may be similarly implemented at other institutions seeking to improve consultation communication.

We acknowledge the members of the Lucile Packard Children’s Hospital pediatric residency and subspecialty fellowships who were integral in the success of this study. Specifically, we thank the Fellow’s QI Council who made this study possible.

Dr McHugh’s current affiliation is Department of Pediatrics, Boonshoft School of Medicine, Wright State University, Dayton, OH.

Dr Pavitt's current affiliation is the Department of Neurology, Child Neurology, University of California, San Francisco, San Francisco, CA.

Drs Pavitt, McHugh, Chi, Hoang, Lippner, and Bassett conceptualized and designed the study, designed the data collection instruments, collected data, conducted the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Tsai and Goldstein conceptualized and designed the study, collected data, and reviewed and revised the manuscript; Dr Srinivas conceptualized and designed the study, coordinated and supervised data collection and analysis, and critically reviewed and revised the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

ECE

essential consult element

EHR

electronic health record

PDSA

plan-do-study-act

PGY

postgraduate year

QI

quality improvement

SBAR

situation-background-assessment-recommendation

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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