The chaotic emergency department is chock full of rapid fire critical communications, but most spend little time planning and assessing the effectiveness of their communication methods. More than half of sentinel events of patient death or permanent injuries due to treatment delays occur in EDs, according to the Joint Commission. Analyses reveal that an astounding 84 percent of EDs cite communication as a root cause. (Joint Commission, Sentinel Event Alert; June 17, 2002; http://bit.ly/JCdelays.)
In January, the Emergency Dep-art-ment Benchmarking Alliance — 412 U.S. EDs encompassing more than 16 million visits — began informally studying its members' communication strategies, finding they used a variety of low- and high-tech methods. (See table.)
Census and Layout
The size and structure of an ED greatly influence optimal communication methods. In a 12,000-visit, eight-bed, 2000-square-foot facility, simple traditional methods such as face-to-face communication and flagging written orders on the chart may suffice. In a 130,000-visit, multi-unit, 35,000-square-foot palace, more sophisticated strategies are required. Face-to-face communication gives way to radios in mid-volume EDs because the footprint is larger, and direct communication is more difficult to carry out. But as volumes go up, radios become less usable because of ambient noise and interruptions. (Med J Aust 2002;176:415.) It also has been observed by high-volume EDs in the alliance that as the ED footprint and number of users increase, the reliability of all radio communication decreases. Ultrahigh-volume EDs eventually arrive at dedicated cell phones with speed dialing and text messaging.
Regardless of size, certain principles apply. Convenience is an unspoken threshold by which providers often decide whether to pursue communicating essential messages. Proximity and accessibility support frequent interaction. Physical layouts that foster privacy, afford clear lines of sight, and include common work and gathering spaces will facilitate good communication habits. Two studies have shown that face-to-face communication is still the most common means of transmitting patient care information, usually via the charge nurse. (Ann Emerg Med 2007;50:396; Ann Emerg Med 2007;50:407.) EDs organized by work teams in geographic zones will see enhanced communication and improved workflow. William Beaumont Hospital in Royal Oaks, MI, perhaps one of the most efficiently run high-volume EDs in the country (according to performance metrics submitted to EDBA annually), sees 400 patients a day in seven geographic zones staffed by separate teams.
In larger EDs, ancillary services such as radiology and laboratory dedicated to the ED and stationed in close proximity, encourage teamwork, and result in a higher functioning unit. In unpublished data from Premier Consulting Solutions, dedicated radiology and laboratory services in the ED correlated with better performance on time metrics. (Jeanne McGrayne, The Advanced ED Management Course [presentation], March 10, 2010.) EDs fortunate enough to have a dedicated pharmacist are more likely to receive greater medication oversight, partly because of increased informal communications. (Ann Emerg Med 2010;55:513.)
The communication patterns and needs of physicians and nurses are different. Think about this: Nurses may communicate effectively in the department without using patient names. “Judy, can you get a catheterized urine specimen in bed 3?” “Linda, can you take more Zofran to room 6?” “Dr. Welch, can bed 4 have more pain meds?” Most communication is entirely local within the department, and when nurses call the floors to give report, they typically use a landline with the paperwork in front of them.
Physician calls, however, will frequently be to those outside the ED, often outside the building. Private health information, including the patient's name, needs to be exchanged. This makes dedicated cell phones the preferred route of communication for physicians. While nurses are comfortable with radios, in particular voice lanyards, these loudly interrupt physicians at the bedside or during consultations, and they are perceived as disruptive by patients as well. The nurses at the Christiana Care ED in Wilmington, DE, with 114,000 yearly visits, use lanyards, and the physicians use dedicated cell phones. These lanyard radios also can be used to call physicians on their phones.
A few EDBA members have noted that transitioning to computerized physician order entry can adversely affect communication because the old visual cues (flagging a chart) may be lost. If you transition to CPOE by physicians, still consider the need to cue the staff. Keep in mind that a computerized icon is simply not as effective as other visual cues.
The ideal communication will depend on many factors. An urgent message demands to be communicated quickly. An overhead distress page is still an effective way to get an immediate response to a highly urgent situation. Less urgent communication may be sent by radio messages or cueing such as a whiteboard or visual prompts. A message's privacy also may require one-on-one communication, and patient confidentiality in the ED is a growing concern. The need to target the message to a particular recipient can be met by a dedicated phone call, text, or voice mail. These techniques will be less disruptive to the ED while still delivering information in a timely way. The length and complexity of the message also can dictate the communication choice, with two-way communication being best. Sometimes staff members simply need to talk about complex patients. Longer messages are best handled through a face-to-face conversation or phone call.
Subtleties embedded within communication may make one option more desirable than another. An order for pain medication in a patient with a kidney stone may require more urgent communication (a phone call or text) than a less urgent message about chronic pain management, for which chart cueing may suffice.
How do you know your ED's communication is functioning optimally? Objective measures are difficult to quantify. Lean methodology suggests simply measuring the distance each provider must travel to perform his tasks. Waste of movement occurs when there are repeated attempts to communicate with another provider. This has been measured by observers counting the steps taken to care for a number of patients. A more practical approach is for the provider to wear a pedometer.
EDs also can monitor the frequency of each modality used or monitor subcycle times for ED processes. As communication is optimized, delays due to communication constraints should begin to decrease. Perhaps the simplest way to measure improvement in communication comes from qualitative research techniques: measure staff satisfaction. Most survey tools that measure safety now include a “teamwork and communication” portion as a key piece of the investigation.
Any enhancements to your communication system will improve quality, safety, efficiency, and flow. Deliberately assessing your ED's needs and your current system's efficacy and reliability is a worthwhile endeavor. Most ED communication systems were not designed but evolved haphazardly. Even if your needs are being met, you can decrease interruptions (a source of medical errors) by stratifying communication by hierarchy, and designing rules that clarify when staff may interrupt physicians and nurses doing clinical work. (One study observed 36.5 communication events per person in an ED in a 35-minute interval, and a third were interruptions! [Med J Aust 2002;176:415.])
One day, operations research should identify the gold standard for ED communications, stratifying the best strategies by volume. The sophisticated ED will utilize multiple approaches purposefully chosen to meet their unique needs. For now, improve on whatever system you are using by recognizing that nuances in ED communications dictate which modality is optimal for a particular message, that the noise level in most EDs is too high, and that the communication needs of physicians, nurses, and staff are different. EDs also need to limit interruptions and improve overall communication strategies, assess the effectiveness of their current system, and embrace new technology; it can improve workflow!
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Dr. Welch is a fellow with Intermountain Institute for Health Care Delivery Research, an emergency physician with Utah Emergency Physicians, and a member of the board of the Emergency Department Benchmarking Alliance. She has written two books on ED operational improvement; the latest, Quality Matters: Solutions for the Efficient ED, is available from Joint Commission Resources Publishing. Dr. Cheung is a Malcolm Baldrige National Quality Award Examiner, former faculty of the Johns Hopkins Center for Innovation in Quality Patient Care and the Quality and Safety Research Group, and a member of ACEP's Quality and Performance Committee.