Communication is of great importance in medicine and the single biggest factor in most errors. Psychiatric practice has an even greater focus on communication. So it goes without saying that good communication is essential.
One of the common tasks for a junior medical officer is that of giving handover. These days the adoption of a structured mnemonic to aid handover in and across institutions has become common place. There are many such mnemonics now in place (a literature review in 2009 by Reisenber, Leitzsch and Little identified at least 24 versions). The one most commonly adopted in the Australian context is ISBAR, which stands for:
OR sometimes Reccomendation
Videos streamed under Standard YouTube license, with acknowledgement to HNE Health, Australian Commission on Safety and Quality in Healthcare and Western Health
Below I have written some tips about how to use ISBAR in the mental health context based on my personal experiences working with junior doctors over the years as well as the experience of colleagues.
I've written these from the perspective of an Intern or Resident who might be seeing patients in a range of settings (e.g. Emergency Department, Medical Ward, Mental Health Unit or even General Practice) and then might be needing to do a handover to a more senior colleague or perhaps the rest of the team.
This is where you introduce yourself to the person or persons you are discussing the patient with. It goes without saying that in certain circumstances you can skip this bit, for example when you have been working on a unit for a while you don't need to introduce yourself to the other members present at the ward round (unless there is someone new)
Don't forget that the person you are talking to might not work at the same place, particularly if you are calling a Registrar or Consultant after hours. Psychiatry doctors tend to cover a number of hospitals and services after hours so its helpful to say:
- your name
- where you are working
- what your position is
Tip: Don't be afraid to highlight your inexperience, Psychiatrists are generally very friendly and empathic and keen to help out. We often deal with clinicians on the phone that we are not familiar.
Hi I'm Mike Teavee, I'm working as a Resident Medical Officer on the Acute Adult Ward at Charles Hospital and it's my first week working in psychiatry.
Finally, consider that the person you are talking to on the phone may be coming to see the patient and again might not work at the facility you are working at. Will you be there when they arrive? Will they know how to find you?
When I was a Registrar I found the experience of seeing patients in the Emergency Department a bit frustrating at times. Often the emergency doctor who had rung me had finished their shift and not always handed over well to a colleague. It was always a good experience when I walked in and a member of the emergency team identified themselves to me as looking after the patient.
In most cases we are trying to get to “R” as quickly as possibly so that we can request or recommend an action.
So here we want to briefly summarize the primary problem and this should hopefully link to whatever the request or recommendation is.
It may also vary according to circumstance:
e.g. Ward Round
We are reviewing Ms Veruca Salt who is a 35 year old woman admitted 3 days ago with a relapse of Bipolar Disorder
or phoning from the Emergency Department
Augustus Gloop is a 54 year old man presenting with an overdose of prescribed medication in the context of alcohol, he is currently physically stable, talking and conscious
Note in the second example we are giving the person to whom we are referring to some very important basic information (i.e. that the person is in a good position now to see a mental health clinician). If you were to only say:
Augustus Gloop is a 54 year old man presenting with an overdose of prescribed medication in the context of alcohol
And then launch into Background and Assessment. I would be left wondering whether there were more urgent things to attend to.
This is where you present the pertinent bits of history.
How much you present again depends on the circumstances but in most cases its best to present only the significant positive findings and any key relevant negatives. The person or team you are referring to may ask questions at the end of your ISBAR which is perfectly okay.
Some things that ARE USEFUL to know in a psychiatry ISBAR (in my opinion) are:
- Past admissions, in particular how long ago and what were the circumstances, is the current presentation similar to the past or completely different?
- Past history of suicide attempts or being aggressive towards others?
- Who are the current people involved in the person's care, are they contactable?
- Who is the person supported by? Have they nominated a next of kin or primary carer?
- Current treatments and past treatments
- Medical problems
- Current problems with substances
- Any current or past legal concerns
This is where you present
- a brief Mental State Exam (positive findings only)
- any relevant findings from physical examination
- risk assessment
RECOMMENDATION / REQUEST
And now we get to “R”
The Request or Recommendation is in my opinion the most important part of the ISBAR handover concept and its a shame sometimes that it comes last.
I'd like to suggest to you that in certain circumstances its actually more sensible to reverse the ISBAR and state your “R” upfront. This would be for example in the situation of an acutely unwell person.
e.g. from the Emergency Department
Hello I'm calling from the Charles Hospital Mental Health Ward, I'd like to request your urgent assistance with a patient who is acutely psychotic and demanding to leave the hospital.
Some common types of “R”s in psychiatry are:
- Review of legal status / need for admission
- Review for discharge
- Review of medications
- Review diagnosis
- Review to confirm delirium or something else
- Review observations and disposition