Talking Saves Lives

IMPROVING COMMUNICATION IN THE EMERGENCY DEPARTMENT

Douglas Syed

Reviewer: Sunny Jutla

The Emergency Department (ED) is a busy place; we all know that much.

Just imagine, for a moment (or perhaps you'd rather not think about it if you're currently in the ED), the number of patients seen daily in your local department.

Let’s take Leicester, for example. The average number of patients seen in a day varies around 600-800, and in 2022, a BBC article highlighted a record-breaking 1000 patients flowing in and out of Leicester’s Adult Emergency in a single day (1). That’s approximately an entire school of students and staff needing the services of our ED every 24 hours. More recently, our numbers have exceeded the 1000 patient mark. The sheer number of people flowing through is bound to cause chaos. All the noise, the people, the crowdedness. Ultimately, this increases the risk of medical errors and mistakes we all dread as healthcare professionals.

This blog post hopes to highlight the ongoing issues surrounding communication in the ED, and most importantly, suggest solutions to prevent fatalities from human factors, improving patient safety and care.

Is handover between different ED members happening?

The little things matter.

The “how” and the “when” we communicate matter, no matter how busy we are. From discharging and writing GP letters to having discussions about the needs of a complex patient; both equally deserve time for a hand-over.

Whenever a patient is stepped down or escalated to another area, we must have a policy in place to hand-over the patient’s situation and plan with staff members in the new area, ensuring the safety of our colleagues and our patients.

We need to involve everyone.

Doctors and Nurses are trained to hand over patients safely, and are also trained in effective and clear communication skills, so the question is… “Why don’t we do more frequent, safe interprofessional hand-overs?”

Is it because we are too busy? Is it because we don’t recognise that there is a need to hand over to one another as our roles differ? Regardless of the reason, the fact is that patient hand-over between doctors and nurses is dwindling.

This needs to change, and fast, for the safety of our patients.

In Aviation, every aircraft’s handover between sectors includes a clear, structured transfer of responsibility, because even a moment of ambiguity can risk error.

In Medicine, our patient handovers must be just as precise; our patients’ lives depend on it.

The Evidence on Human Factors.

So why is this happening?

There are several reasons why there could be a breakdown in communication in the ED:

  • Lack of recognition that a patient is unwell, resulting in no urgency to escalate the patient or discuss the plan with a senior doctor. 

  • No proper recognition of a hand-over between teams in the department.

  • If hand-over was in progress, it may often be interrupted by telephone calls, colleagues needing verbal advice, and external noise.

In addition to these human factors, a very crowded department could also mean that staff are spread thin and are unable to physically attend hand-overs.

Human factors are often discussed in medical simulation and training, but it is still the most common reason for breakdown in communication between teams in practice. 

Human factors:

  • A self-audit by a UK Emergency Medicine Consultant done in 2012 showed that in 25 separate shifts, they were interrupted 718 times (2). Although the original article does not provide if the initial task involved team communications, it demonstrated that interruptions to a task could be minimised if they are done away from a crowded workstation. This is particularly relevant for communication tasks and hand-overs.

  • Another study also observed that emergency physicians are frequently interrupted. In just a short 2-hour period, they saw an average of 30 interruptions (3).

  • These results show the importance of considering performing hand-overs in a separate room to minimise distractions and ensure information is accurate.

Hopefully, this blog reminds you how important learning about human factors to prevent “Never-Events”.

Solution..!

The point of improving patient care is not to add more but to refine the processes that are already in place. 

Currently, we have designated hand-over sheets, and staff are all trained in using the national standardised hand-over method - SBAR.

Since we have a lot of knowledge and policies on “how”, let’s try changing “where” we perform hand-overs.

We all need a bit of space.

No one wants to be meeting in a busy clinical area, shouting over people and the bleeping of machines, as being in a high-stress environment already makes it even harder to communicate.

Even the smallest office would have a dedicated meeting room, so why shouldn’t the ED, where accurate transfer of information is the cornerstone of patient safety?

A new place for hand-overs, starting now.

Introducing a Quiet Zone.

Set aside a designated quiet zone in important areas of the ED - Resus, Majors, and Minors. 

Preferably not the break room or the staff lounge, where people can come in and out, disrupting the meeting.

It could be a room, a cubicle with drawable curtains, or a space with screens set up in a quiet corridor away from patients, but still close enough to respond to any emergencies. 

Even in a busy ED, 2 to 3 minutes of focused transfer can prevent critical errors.

The Future of Safe Communication.

Below is an example of a handover sheet that can accompany every patient’s bedside. 

The main aim is that it is completed by both a doctor and the nurse when the patient arrives in a new area, so both teams are updated on each patient.

To summarise.

Communication in the busy ED is difficult. 

Adherence to the systems put in place is key to putting patients first at the forefront of the care we provide.

Do hand-overs in a quiet room! (or space if a room is not available). This may even improve productivity and quickness of the hand-over. 

Everyone is busy, stressed, and maybe sleep deprived. However, if we have these systems in place, we can rely on them and be assured that distractions are minimal and as little as possible is lost in communication. 

References:

  • Allard J, Wyatt J, Bleakley A, Graham B. "Do you really need to ask me that now?": a self-audit of interruptions to the 'shop floor' practice of a UK consultant emergency physician. Emerg Med J. 2012 Nov;29(11):872-6. doi: 10.1136/emermed-2011-200218. Epub 2011 Nov 22. PMID: 22109536. 

  • Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians "interrupt-driven" and "multitasking"? Acad Emerg Med. 2000 Nov;7(11):1239-43. doi: 10.1111/j.1553-2712.2000.tb00469.x. PMID: 11073472.

Page Contributors

Dr Sunny Jutla
Consultant in Emergency Medicine, Lead for EM3

Tom Brown
Website Designer

Jake Fudge
Multimedia Technologist

Dr Douglas Syed