Referring to Medics

Referring patients to the on-call medical team is a core part of ED work, and often also happens in surgery. How you make that referral sets the tone for inter-specialty relationships and determines how smoothly your patient transitions into inpatient care.

Contexts in which doctors refer to medics

1. Acute admissions (“the take”)
   • Most common: patients with primarily medical presentations who need inpatient care under general medicine (e.g. pneumonia, heart failure, sepsis, DKA, COPD exacerbation).
2. Advice/referral without admission
   • Sometimes a patient is safe for discharge but you want medical input on management (e.g. “Should this new AF be started on anticoagulation?”).
   • In some hospitals, this is discouraged out of hours — always check local policy.
3. Transfer of care
   • Patient initially thought to need surgical/specialty admission but later judged to have a predominantly medical problem.

Example: abdo pain ruled out surgical pathology, but pneumonia found on CXR → refer to medics

Before Referring

1. Check local referral pathways, depending on hospital you might discuss with specialties directly. For example:
   • Chest pain: STEMI → cardiology (sometimes via medics first, depending on hospital).
   • Upper GI bleed → gastro (sometimes via medics first, depending on hospital).
   • Neurological event → stroke team.
   • Collapse/syncope → usually medics unless clear cardiac/trauma cause.
   • Tip: If in doubt, check with ED senior first.
2. Do the ED basics first
   • ABCDE assessment, stabilisation, analgesia, IV access/fluids, oxygen if needed.
   • Initial investigations: bloods, ECG, urine dip, CXR, ABG if appropriate.
   • Start treatment: antibiotics for sepsis, bronchodilators/steroids for asthma, insulin for DKA, etc.
3. Prepare your information
   • Patient identifiers: name, age, sex, NHS/hospital number, location in ED.
   • Presenting complaint, working diagnosis, relevant PMH, current meds, allergies.
   • Observations and NEWS2 score.
   • Results (bloods, ECG, imaging).
   • Treatment so far and response.
   • Why patient needs to be admitted.
   • Ceiling of care / DNACPR if discussed.

During the Referral

1. Introduce yourself clearly

• “Hello, this is Dr James, ED FY2. I’m calling about a patient in majors I’d like to refer for admission under general medicine.”

2. Use SBAR with emphasis on acuity

• Situation:
  • “This is Mr John Smith, a 76-year-old man in majors with respiratory failure secondary to pneumonia.”
• Background:
  • “He presented with two days of cough and fever. Past medical history includes COPD and heart failure. He lives alone and was previously independent.”
• Assessment:
  • “Currently, his obs are: T 38.4, HR 110, BP 96/60, SpO₂ 88% on air, 95% on 4L O₂. NEWS2 is 7. CXR shows right lower lobe consolidation. Bloods: WCC 15, CRP 210, creatinine 160 (baseline 90). He has received IV antibiotics, fluids, and oxygen.”
• Recommendation:
  • “I believe he needs admission under medics for pneumonia with sepsis and AKI. Could you review him with a view to admission? Is there anything else you’d like us to do in ED before transfer?”

3. Be clear about urgency

• Flag unstable patients early. “He is hypotensive and needing oxygen — this is an urgent referral.”

4. Anticipate common questions

• How has he responded to treatment?
• What’s his functional baseline?
• Any ceiling of care discussion?
• Has sepsis 6 been completed?

After the Referral

• Document carefully:
  • Who you spoke to (name, grade, specialty), time of referral, advice given, agreed plan (e.g. “Med reg to review in ED, plan for medical admission”).
• Act on immediate advice (extra bloods, fluids, repeat obs, escalation).
• Escalate if needed: if medics push back and you feel the patient needs admission, involve your ED registrar/consultant to back the referral.

Extra ED-specific etiquette

• Medical registrars are very busy — they may be clerking multiple patients on the take at once, and in some cases may even be covering the wards.  Be concise, prioritise the sickest patients, and hand over efficiently.
• Clarity of responsibility — confirm whether they will review in ED, admit directly, or just advise. Don’t assume!
• Tidy referrals help — have notes, obs chart, bloods, ECGs, and CXR to hand before calling. It prevents back-and-forth.
• Don’t “dump” inappropriate patients — if the issue is surgical, orthopaedic, or psychiatric, refer directly to the right specialty (though sometimes medics will be involved secondarily).

Example Referral Scripts for ED → Medics

1. Pneumonia with Sepsis

“Hello, this is Dr Patel, ED FY2. I’d like to refer Mr John Smith, 76, in majors. He’s presenting with pneumonia and sepsis.

PMH: COPD, heart failure. Functionally independent at baseline.

Obs: Temp 38.4, HR 110, BP 96/60, SpO₂ 88% on air → 95% on 4L O₂. NEWS2 = 7.

CXR: RLL consolidation. Bloods: WCC 15, CRP 210, AKI (Cr 160, baseline 90).

He’s had IV antibiotics, fluids, oxygen. Still borderline haemodynamics.

I think he needs admission under medics for sepsis secondary to pneumonia. Could you review him? Is there anything else you’d like us to do before transfer?”

2. Chest Pain, MI Excluded

“Hello, this is Dr Jones from ED. I’d like to refer Mrs Anne Brown, 68, who presented with chest pain.

ECG: no STEMI. Trop 600 (dynamic rise from 40). CXR unremarkable.

PMH: HTN, diabetes. Obs stable, NEWS2 = 1.

She’s pain free after GTN and morphine. She’s on aspirin and fondaparinux. I think she needs admission under medics with a diagnosis of NSTEMI. Would you be able to review her for admission?”

3. AKI in Surgical Patient (Transfer of Care)

“Hi, this is Dr Ali from ED. I’m calling about Mr David Green, 82, who came in with abdominal pain.

Surgical review found no acute surgical pathology. However, he has severe AKI on CKD (creatinine 400 from baseline 150), hypotension, and likely sepsis from UTI.

He’s had fluids, antibiotics, catheterisation. Still borderline stable.

The surgeons feel his problem is primarily medical, so we’d like to refer him for admission under medics. Could you please review?”

With special thanks to Dr Shyamala Manibalan, senior clinical fellow in care of the elderly and general medicine for her help in drafting the article