Communication in the Emergency Department

Introduction

The Emergency Department (ED) is a unique environment in the medical world and is characterized by a wide variety of presentations. Patients of all different ages seek help in the ED whether they fit into the pediatric, young adult, middle aged, or geriatric populations. The range of acuity presenting is also vast. One minute the ED physician may be treating a sinus infection and the next minute he may be in the trauma bay with a victim of a shooting or a stabbing. The pace is also widely varied, depending on the day of the week or the time of day the work load can range from being nearly unbearable to pleasantly quiet, but it typically favors on the busy side of the spectrum. In this widely varied and dynamic setting, the team based approach to medicine has seen increased popularity because of its necessity in the successful treatment of the ED patient.¹

In these high intensity environments, communication is king. Research has traditionally focused on the communication between the doctor and the patient, but more recently the research has shifted to the communication between members of the medical team.² While these may seem like separate entities, they are actually intimately connected for they both profoundly influence the health and well-being of the patient and the effectiveness of the medical system. A study involving two emergency departments in New South Wales investigated the communication load on medical providers and found that they were engaged in some sort of communicative event for 80% of the total time studied.³ While this was a small study and may not be generalizable to all Emergency Departments, it does show that the vast majority of clinical time in those specific settings was directly involved in communication with or about the patient. So communication in the Emergency Department setting at least warrants discussion and further evaluation.

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Communication with the Patient

An extensive study conducted by the University of Technology in Sydney, Australia evaluated communication in five different emergency rooms over the course of three years and eventually published a 98 page report on their findings. This Emergency Communication Project studied the interaction between patients, providers, and the emergency department environment and from their observations they listed seven different recommendations. Three of the recommendations suggested improvements in the doctor-patient communication, and the rest outlined steps that could improve communication in the emergency department system.⁴

Their study found that communication in a variety of modalities through various mediums was intricately woven into every facet of Emergency Room care, and that the successful execution of communication was vital to each patient’s ED experience and to each provider’s work satisfaction. They also found that the quality of patient care suffered due to a prevalence of complex information sharing and the prioritization of gathering medical information over establishing patient relationships.⁴

Their first recommendation involves balancing the medical and interpersonal. In communicating medical information they recommend asking open ended questions, allowing the patient time to communicate their complaint, establishing their medical understanding, avoiding medical jargon during explanations, delineating the treatment plan clearly, incorporating shared decision making, and repeating key information. For establishing interpersonal relationships, they recommend introducing yourself as the physician, using inclusive and colloquial phrases, complimenting and supporting, being empathic and sharing humor when appropriate, and being culturally sensitive.⁴

They also recommend offering detailed explanations about the ED world that is likely foreign to most patients. They suggest that having an ED “orientation protocol” can contribute to decreased patient anxiety and increased understanding and awareness. They also recommend thoroughly explaining triage categories and expected wait times.⁴ This is congruent with other studies that have found that patient satisfaction in the ED is directly related to perceived wait times, not actual wait times.^5,6. And a patient’s perception can be affected by explanation and information.⁶ Slade et al. also recommend explaining procedures and tests so patients know what to expect, and then giving a thorough clinical explanation and the rationale supporting the final diagnosis and treatment plan. These steps assist in keeping the patient informed and aware of what is happening in their care.⁴

The final patient centered communication recommendation that is given from the Emergency Communication Project relates to cross-cultural awareness. They mention that the emergency staff in their study was a diverse group consisting of many providers whose first language was not English. They also had locum tenens doctors who were only there temporarily and did not fully understand that culture or that medical specific system. Their patient population was also quite diverse. In such settings and in the ED where communication is vital to the efficiency and efficacy of the team, they recommend that the staff at least be oriented and ideally trained to work successfully in a culturally diverse work environment.⁴

Another study that involved retrospective analysis of patient completed surveys in a pediatric emergency department investigated patient satisfaction as a function of the willingness of that patient to recommend that emergency department’s services. After controlling for multiple variables, the study found that the strongest correlation with patient satisfaction was whether or not the patient and family felt informed by the medical staff during their stay.⁷ Again, communication is vital to patient satisfaction and care.

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Communication with the Medical Team

A large study conducted at two academic emergency departments in England identified four crucial communication points in patient care that predetermined the efficacy of their treatment and sometimes the occurrence of adverse events. They described these communication events as occurring during triage, while testing and evaluating, during handoffs, and while admitting patients to the hospital.⁸ Other studies have investigated specifically the physician “handoff” or “sign-out” period and have shown that communication failures at this crucial time leads to increased uncertainty for medical providers and worse outcomes for patients.^2,9 These transitions in patient care from one provider to another, or from one specialty to another have been investigated and experts have made suggestions on how to correct deficiencies, but now inter-departmental communication is also being studied to further develop and refine communication with the goal of improving patient care.^2,10

With regard to transition of care, Arora et al. found in their study that poor sign-outs often omitted important patient information, were not face-to-face, and involved illegible written communication. Their conclusion was that an effective sign-out included important patient data (code status, potential problems, baseline exam, pending tests/results) with the written portion being legible, accurate, and current. They also recommend that the verbal component be face-to-face, pertinent, and thorough.⁹ Eisenberg et al. echo the sentiment that transfer of care communications should occur face-to-face and they suggest having the patient present, specifically with regard to consulting physicians in the ED. They also recommend that the entire communicative process during ED consultations be improved and standardized to avoid miscommunication.⁸

Communication within the emergency department itself has also proven to be a challenging feat. Multiple studies have identified two separate entities that make communication in the ED especially difficult. Because of the unique work environment, ED physicians are constantly experiencing interruptions in communication and are multitasking at a much greater rate than other physicians. One study found that 10% of the time ED physicians were involved in more than one conversation at a time. That same study found that 31% of the total communication time was spent in addressing interruptions.² Another study that compared the interruption rate of ED physicians with primary care physicians found that ED physicians experience twice as much interrupted communication in one hour. They also found that ED physicians in their study were managing the care of three or more patients at an average of 37.5 minutes per hour while primary care physicians managed multiple patients 0.9 minutes per hour.¹¹

Because of the heavy communication load, frequent interruptions, and constant multi-tasking, the emergency department is a volatile environment that can breed miscommunication if not closely guarded. Further research is needed to correlate breakdowns in communication with medical errors, but this is often difficult due to the complexity of the ED system. Most likely, medical errors are the result of multiple factors.²         

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Conclusion

Good communication is absolutely vital in all areas of medicine, but maybe even more crucial in the emergency department. While research has discovered pitfalls and offered insightful solutions, there is still research needed on improving doctor-patient communication and medical team communication in the emergent environment. Until then, we can consider Grice’s communication maxims of quality, quantity, relevance, and manner. “Be truthful, be informative, be relevant, be clear.”²

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Intel

1. Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaethesiol Scand 2009; 53:143-151.
2. Coiera E. Communication in Emergency Medical Teams. In: Patient Safety in Emergency Medicine. Lippincott Williams & Wilkins, 2009.
3. Coiera E, Jayasuriya RA, Hardy J, Bannan Aiveen, Thorpe MC. Communication loads on clinical staff in the emergency department. Med J Aust 2002 May 6;176(9):415-8.
4. Slade D, Manidis M, McGregor J, et al. Communicating in Hospital Emergency Departments. Final Report. Sydney: University of Technology Sydney, 2011.
5. Boudreaux ED, Friedman J, Chansky ME, Baumann B. Emergency department patient satisfaction: examining the role of acuity. Acad Emerg Med 2004 Feb;11(2):162-8.
6. Thompson DA, Yarnold PR, Williams DR, Adams SL. Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department. Ann Emerg Med 1996 Dec;28(6):657-65.
7. Johnson MB, Castillo EM, Harley J, Guss DA. Impact of patient and family communication in a pediatric emergency department on likelihood to recommend. Pediatr Emerg Care 2012 Mar;28(3):243-6.
8. Eisenberg EM, Murphy A, Sutcliffe K, et al. Communication in emergency medicine: implications for patient safety. Communication Monographs. 2005;72(4):390–413.
9. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care 2005 Dec;14(6):401-7.
10. Fairbanks RJ, Bisantz AM, Sunm M. Emergency department communication links and patterns. Ann Emerg Med 2007 Oct;50(4):396-406.
11. Chisolm CD, Dornfeld AM, Nelson DR, Cordell WH. Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med 2001 Aug;38(2):146-51.