In complex environments like surgical ICUs, integrated team performance and effective communication skills are vital to positive patient outcomes. These skills are critical because breakdowns in communication have reportedly been responsible for nearly 85% of sentinel events that lead to increased length of stay in the hospital, higher morbidity, and more litigious actions. Patients most susceptible to negative outcomes as a result of communication errors are those who are acutely ill in the surgical ICU. Improving communication among healthcare teams enhances the quality of care and has the potential to reduce the likelihood of negative patient outcomes.
Identifying Communication Barriers
In surgical ICUs, it’s important to ensure that the knowledge and experience of attending surgeons are appropriately utilized by the residents and fellows executing the care. Anytime there is a communication breakdown or a barrier that prevents essential information flow, there is a risk of accentuating negative patient outcomes either directly or indirectly. In the January 2010 Journal of the American College of Surgeons, my colleagues and I initiated a prospective observational trial to evaluate communication between surgical ICU residents and fellows following the occurrence of hypotension, new arrhythmias, desaturation, and tachypnea. Our study found that a third of these critical events were never reported to an upper level physician, and a quarter of these events resulted in negative short-term outcomes.
There are many reasons why these events may not be properly communicated to senior surgeons, including overconfidence, complacency, and/or fear of appearing to be incompetent. Much of this behavior is attributed to the traditional evaluation of medical students where individual performance is rewarded. However, it’s clear that efforts are needed to make residents and fellows more comfortable asking for help in making decisions so that patients receive the best care possible.
Interventions May Enhance Outcomes
Following the observational phase of our study, we implemented an intervention that was designed to encourage and provide a conduit for improved communication. The goal was to emphasize collective teamwork over singular performance. A seminar was initiated in which acceptable ways of accessing superiors were discussed. Residents were encouraged to utilize these strategies even if it meant making several calls to senior attending surgeons. Furthermore, a policy was instituted in which fellows were required to call the surgical ICU and speak to residents at least once during night shifts. This provided a regular opportunity for residents to engage fellows and communicate any issues that might have come up during shifts. In an analysis of short-term outcomes following the intervention during late shifts, residents improved their overall communication of events by 10%, and 90% of all successfully communicated events in the study demonstrated improved short-term outcomes.
Technological & Cultural Solutions
Fostering communication has the potential to improve short-term patient outcomes, and direct interventions similar to the one utilized in our study can help. Technological solutions, such as the use of monitors that send smart-alert pages if vital signs cross a preset threshold and eICU stations where intensivists can monitor several ICUs from one place, provide additional resources to enhance communication and promote better care for patients. A paradigm shift is occurring in the evaluation of undergraduate medical students as curriculums are moving away from individualized study and toward problem-based learning. The hope is that more students will utilize the expertise of their colleagues in challenging medical situations. Embracing a teamwork approach can increase the likelihood of positive patient outcomes.
Readings & Resources (click to view)
Williams M, Hevelone N, Rodrigo A, et al. Measuring communication in the surgical ICU: better communication equals better care. J Am Coll Surg. 2009;210:17-22. An abstract is available at: http://www.journalacs.org/article/S1072-7515%2809%2901402-1/abstract.
Lingard L, Epsin S, Evans C, Hawryluck L. The rules of the game: interprofessional collaboration on the intensive care unit team. Crit Care. 2004;8:403-408.
Reader TW, Flin R, Mearns K, Cuthbertson BH. Interdisciplinary communication in the intensive care unit. Br J Anesth. 2007;98:347-352.
Pronovost P, Berenholtz S, Dorman T, et al. Improving communication in the ICU using daily goals. J Crit Care. 2003;18:71-75.
Williams RG, Silverman R, Schwind C, et al. Surgeon information transfer and communication. Factors affecting quality and efficiency of inpatient care. Ann Surg. 2007;245:159-169.
Reader TW, Flinn R, Mearns K, Cuthbertson BH. Developing a team performance framework for the intensive care unit. Crit Care Med. 2009;37:1787-1793.