Rapid fire delivery of critical information between clinicians is commonplace in the ED, but most departments rarely plan and assess the effectiveness of their communication methods. Research has indicated that more than half of all sentinel events—death or permanent injury due to treatment delays—occur in EDs, according to the Joint Commission. Analyses have shown that communication is the root cause for the majority of these events. “Few investigations have looked into how communication of information within the ED can be optimized,” says Shari Welch, MD, FACEP.
In an effort to examine communication practices within the ED and assess strategies that may improve these efforts, the Emergency Department Benchmarking Alliance, which comprises 412 EDs in the United States, began to study its member’s communication strategies. The initiative demonstrated that most EDs use a variety of low and high-tech methods for communication (Table 1).
In the 1980s, the whiteboard was commonly used to display and convey information within the ED. Now, that trend has given way to computerized systems, according to Dr. Welch. “Physicians and nurses could circle something on a whiteboard to denote importance, but the tracking screens that are used frequently now do not give the same visual cues.” Many EDs have begun using overhead paging more frequently. However, in the average ED, according to the World Health Organization, the decibel level of noise is often too high, causing stress for both staff and patients.
Emergency Department Size & Needs
“Smaller EDs are much more efficient with their communications than larger ones,” Dr. Welch says. “Larger EDs can be burdened by their structure. Many have long hallways, no central work areas, and have leaded walls from the radiology suites that prevent radio communication. These factors can decrease the effectiveness of any communication. The lesson here is that larger EDs should try to structure their facilities so that they are equipped to handle peaks and valleys of ER arrivals without sacrificing communication.”
The communication patterns of nurses often differ from those of physicians. They tend to communicate mostly within the department and use room and bed numbers rather than patient names. Physicians, however, frequently make calls outside the walls of the ED and hospital to other physicians. These calls tend to include patient names and other protected health information. “When looking at improving communication strategies, it’s important that EDs factor this into the interventions that are created,” says Dr. Welch.
Communication Options in the ED
According to Dr. Welch, the ideal communication strategy will depend on the acuity of the information. “An emergent message needs an immediate, fool-proof communication to the right people, and an overhead page is functional for this. However, some EDs overuse overhead pages, which can then be ignored. For urgent and semi-urgent communications, dedicated cell phone calls or texts may be effective too.”
Some EDs are now using voice necklace radios to combat issues with overusing overhead pages, but these may be disruptive for physicians and patients who are receiving care. “The key is to assess the potential usefulness of tools, discuss them with ED staff, and then work collaboratively to establish a strategy that benefits all staff members. Most EDs have never taken time to plan a communication system within the department.”
Measure Effectiveness of ED Communication
When determining if ED communication is functioning optimally, Dr. Welch says it is important to look at strategies that minimize wasted movement (Table 2). “If staff members are trying to find patients or physicians and getting frustrated because they need to convey information, the resulting effect can be catastrophic. The efficacy of the department will suffer if communications are fractured. The morale of the ED is also likely to be lower, especially as frustrations set in more regularly.” To assess if movement is being wasted in EDs, Dr. Welch recommends that staff wear pedometers to measure how far they walk in a given period. Trialing new communications during these assessment periods will help determine wasted movements. ED leaders can then review with staff strategies that may minimize this waste. “You can survey staff and find out about their frustrations,” adds Dr. Welch. Devices that measure decibels are also available and may be of benefit to assess noise levels that can add stress.
Taking Action to Improve Communication
“Communication is critical to the care that emergency physicians give every day,” she says. “In the ED, operations science and management are far behind other industries. Paying attention to communication systems within the ED will hopefully help us catch up.”
Readings & Resources (click to view)
Welch S, Dickson C. Quality matters: Enterprise to McCoy: The future of communications in the ED. Emerg Med News. 2011;33:20-21.
Siassakos D, Bristowe K, Hambly H, et al. Team communication with patient actors: findings from a multisite simulation study. Simul Healthc. 2011;6:143-149.
Kessler C, Kutka B, Badillo. Consultation in the emergency department: a qualitative analysis and review. J Emerg Med. 2011 May 25 [Epub ahead of print]. Available atwww.sciencedirect.com/science/article/pii/S0736467911003714.
Johnson K, Winkelman C. The effect of emergency department crowding on patient outcomes: a literature review. Adv Emerg Nurs J. 2011;33:39-54.