Communication in Emergency Medical Teams - CiteSeerX

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CHAPTER 26

Communication in Emergency Medical Teams E. Coiera

Introduction Elements of a Communication System Communication Patterns in Emergency Care Settings Communication Across Transitions in Care Communication Loads, Interruptions, and Multitasking

The Role of Communication in the Genesis of Adverse Events Improving Communication Practices in the Emergency Care Setting Standardizing the Content and Format of Communications Use of Communication and Computer Technologies to Support Safer Practice

Conclusion Summary References

INTRODUCTION The focus of most clinical communication research and training has for many years been on the clinician-patient relationship (1). Only recently has the focus begun to shift to recognize the crucial role of communication within and between clinical teams and organizations for effective organizational performance and safe clinical practice. We are beginning to realize that communication failures are a large contributor to adverse clinical events and outcomes. Communication failures have been identified at the root causes of more than 60% of the sentinel events reported to The Joint Commission on Accreditation of Healthcare Organizations (2). In a retrospective review of 14,000 in-hospital deaths, communication errors were found to be the leading cause, twice as frequent as errors due to inadequate clinical skill (3). About 50% of all adverse events detected in a study of primary care physicians were associated with communication difficulties (4). If we look beyond the raw numbers, the clinical communication space is interruption-driven, with poor communication systems and poor practices (5). Communication patterns and their implications for safety have recently received significant attention in emergency medicine. In recent years, researchers have repeatedly identified that the emergency department (ED) is a challenging, highvelocity, multitasking, and high-interrupt setting that stresses even the very best communication practices (6,7). Other professional communities with a strong safety culture, such as the airline industry, have identified the nexus between system safety and effective team communication and have developed clear communication protocols and practices as a result. Although much still remains to be learned about clinical team

communication in the ED, we now have a sufficiently clear model of the typical challenges clinicians face in this setting. In this chapter, we examine the basic elements of a communication system and then review what is known about ED team communication, the links between communication patterns and unsafe clinical practices, and the emerging consensus on team communication policies and systems that can minimize the impact of communication mishaps on patient safety.

ELEMENTS OF A COMMUNICATION SYSTEM Communication systems are the formal and informal structures organizations use to support their communication needs. A communication system involves people, the messages they wish to convey, the technologies that mediate conversations, and the organizational structures that define and constrain the conversations that are allowed to occur. Elements of communication systems include the following (8): • Communication channels: The channel is the pipe along which a message is conveyed. There is a wide variety of different communication channels available, from basic face-toface conversation, through telecommunication channels like the telephone or e-mail, to written channels like the medical record. Channels have attributes like capacity and noise that determine their suitability for different tasks. When two parties exchange messages across a channel at the same time, this is known as synchronous communication. Telephones are one of the most commonly used two-way synchronous channels. It is the nature of synchronous communication that it is interruptive, and these interruptions can have a negative impact on individuals who have high cognitive loads. For example, a busy clinician might forget to carry out a clinical task because he or she has been interrupted. In contrast, when individuals are separated in time, they might use an asynchronous channel to support their interaction. Since there can be no simultaneous discussion, conversations occur through a series of message exchanges. This can range from adhesive notes left on a colleague’s desk to the use of a sophisticated electronic messaging system. One of the benefits of asynchronous communication is that it is not inherently interruptive. If a communication is not urgent, asynchronous channels can be a preferred way to communicate with otherwise busy individuals. • Types of messages: Messages are structured to achieve a specific task using available resources to suit the needs of the receiver. Informal messages, which have variable structures, include voice and e-mail messages. Structured or formal 181

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SECTION V • IT’S ABOUT THE TEAM, IT’S ABOUT COMMUNICATION

messages include hospital discharge summaries, computergenerated alerts, and laboratory results. • Communication policies: A communication system can be bounded by formal procedures as well as by technology. A hospital might have many different policies that shape its communication system performance independent of the specific technologies used. For example, it might have a policy to prohibit general practitioners from requesting a medical record directly from the records department without the permission of a hospital clinician. Grice’s conversational maxims (Table 26.1) can be considered general rules for effective and clear communication. • Individuals: A communication system can be specifically constructed around the individuals involved in the different information transactions. For example, in a busy clinical unit, one could devise a system where a ward clerk fields all telephone calls. The clerk’s specific communication role is thus to minimize interruption of clinical staff.

• Communication services: Just as computer systems can run a number of different software applications, we can think of a communication system providing a number of different communication services. Voice communication is only one of the many services available across a telephone line. Fax transmission of documents is an entirely different kind of service that uses the same underlying channel. For example, a mobile phone can provide voice mail, text messaging, and Internet browsing services. • Communication devices: Communication services can run on different communication devices. Examples of devices include the telephone, fax machine, and personal digital assistant (PDA). Different devices are suited to handle different situations and tasks. Communication devices are a source of continuing innovation. One area of recent interest has been wearable computing, where devices are small enough to become personal accessories like wristwatches or earrings.

T A B L E 2 6 . 1 Grice’s Maxims

How is it that humans manage to communicate effectively given the inherent limitations of the communication process? More importantly, given that poor communication can have a profound negative impact on health care delivery, what defines good communication practice? One of the most influential answers to these questions comes from the work of H. Paul Grice (9), who took a very pragmatic approach to the mechanics of conversation. Grice suggested that we all communicate according to a basic set of rules that ensures conversations are effective and that each agent understands what is going on in the conversation. Most generally, the cooperative principle asks each individual that participates in a conversation to do his or her best to make sure it succeeds. Individuals should only make appropriate contributions to a conversation, saying just what is required, saying it at the appropriate stage in the conversation, and only to satisfy the accepted purpose of the conversation. Grice proposed a set of four maxims, which explicitly defined what he meant by the principle of co-operation: Maxim of Quantity: Say only what is needed. Be sufficiently informative for the current purposes of the exchange. Do not be more informative than is required Maxim of Quality: Make your contribution one that is true. Do not say what you believe to be false. Do not say that for which you lack adequate evidence. Maxim of Relevance: Say only what is pertinent to the context of the conversation at the moment. Maxim of Manner: Avoid obscurity of expression. Avoid ambiguity. Be brief. Be orderly. The maxims overlap, but they lay out a set of rules that guides how conversations should proceed. Clearly, people do not always follow these maxims. Sometimes it is simply because individuals are not “well behaved.” At other times, individuals break the rules on purpose to communicate more subtle messages. For example, people are often indirect in their answers when asked a question. If someone asked you, “How much do you earn?” a wry answer might be, “Not enough!” or something similarly vague. Such an answer clearly is uncooperative, and violates the maxims of quantity, relevance, and manner in different ways. However, the clear message behind the answer is, “This is none of your business.” The intentional violation of maxims allows us to signal concepts without actually having to say them, either because it might be socially unacceptable, or because there are other constraints on what can be said at the time.

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CHAPTER 26 • COMMUNICATION IN EMERGENCY MEDICAL TEAMS

• Interaction modes: The way an interaction is designed determines much of the utility of different communication systems. Some modes of interaction, for example, demand that the message receiver pays attention immediately, such as the ringing tone of a phone, whereas others can be designed not to interrupt. An asynchronous service that is inherently not interruptive, like e-mail, can still be designed with an interruptive interaction mode, such as the ringing of a computer tone when a message arrives, altering the impact of the service on the message receiver. A communication system is thus a bundle of different components (human, technical, and organizational), and the utility of the overall system is determined by the appropriateness of all the components together. If even one element of the bundle is inappropriate to the setting, the communication system can under-perform.

COMMUNICATION PATTERNS IN EMERGENCY CARE SETTINGS COMMUNICATION ACROSS TRANSITIONS OF CARE The ED has been characterized as having four routine communication processes: triage, testing and evaluation, handoffs, and admitting (10). Most attention has been paid to communication breakdowns that occur at the interfaces or transitions in care. During transitions, there is a handoff of responsibility from one clinician to another that involves the transfer of rights, duties, and obligations for the care of patients (11). Such handoffs introduce a discontinuity in care where errors might occur. These transitions occur regularly at shift changes or whenever there is transfer of the patient from the care of one clinical team to another. There is an inverse relationship between the number of hours worked in a shift and the number of times a patient has care transferred in any 24-hour period. Work-hour limitations thus result in an increase in the number of transfers of patient care (12). A significant transitional event in the ED is the sign-out of a patient from the ED, for example, moving back into the community. Handoffs have been identified as a significant cause of inefficiency and error. In one study, patients who were admitted by a cross-covering resident and then transferred to a different resident the following day had more hospital tests and a longer hospital stay compared with patients whose care was continuous (13). A critical incident study focusing on written or verbal communications at the time of transfer of patient care between firstyear residents identified 26 discrete incidents from 26 interns caring for 82 patients, all the result of communication failure at the sign-out (2). Major event classes included the omission of important clinical information (such as medications, pending tests, and active problems) and failed communication processes (e.g., failure to have a face-to-face discussion). In nearly all cases, the study authors reported that critical events led to uncertainty in subsequent decisions about patient care. Communication of information at significant stages in the care of patients remains problematic in many EDs. Yet the approach to ED handoffs remains highly variable. A 2007 nationwide survey of United States (US) training programs

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reported that 89.5% had no uniform written policy regarding patient sign-out in their EDs, 50.3% exclusively used verbal sign-outs, and 42.9% rarely documented transfer of attending responsibility (14).

COMMUNICATION LOADS, INTERRUPTIONS, AND MULTITASKING Although there has been much concentration on communication breakdown at transitional events such as handovers, more recent research has focused on communication that occurs within teams while they are engaged in active patient care. It is particularly useful to conceive of the ED as a communication environment and to characterize the attributes of this communication space (15). For example, the physical environment, work loads, and work processes all interact to shape the way people communicate and the way that things can go wrong. In recent years we have begun to develop a rich picture of communication patterns in the ED communication space. Studies from around the world paint similar pictures of hospitals, and EDs in particular, as busy, interruption-driven, and multi-tasking environments (6,7). It is difficult to identify common interruption rates for the ED, as there are various definitions of what constitutes an interruption, as well as differences in case load, staffing experience, and departmental organization, all of which can affect communication loads and interruption rates. In one set of Australian studies using the same observational method over a period of two years, average ED interruption rates ranged from 11.2 (6) to 14.8 (16) per person per hour. Interruption rates varied significantly between clinical roles. Medical registrars and senior nursing coordinators experienced the highest rates of interruption, with 23.5 and 24.9 interruptions per hour. Nurses and junior doctors had lower rates, at 9.2 and 8.3 interruptions per hour. When benchmarked against other clinical specialties, emergency clinicians seem to have higher communication loads as measured by interruption rates and multitasking. A U.S. study comparing ED physicians with office-based primary care physicians found interruption rates in the ED of 9.7 per hour compared to 3.9 in primary care (7). Whereas ED physicians in this study spent, on average, 37.5 minutes of every hour managing three or more patients concurrently, primary care physicians spent less than 1 minute per hour under such multi-tasking loads. Rates of interruption in the ED seem to correlate strongly with shift intensity, as measured by the average time from patient registration to physician evaluation (17). Although raw interruption rates and multi-tasking loads provide some insight into the total communication load on individuals in a clinical team, efforts continue to develop more accurate workload measurements that account for both subjective and objective criteria (18).

THE ROLE OF COMMUNICATION IN THE GENESIS OF ADVERSE EVENTS Although we now know something about the typical patterns of team communication expected in the ED, much less is known about the link between communication and error. Very

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few studies have gathered actual data connecting communication and error, making this an urgent focus for the research community. Communication can be delayed, avoided, or ineffective for some very basic human reasons. In circumstances where there is a clear difference in the positions of two individuals in an organization’s hierarchy, the more junior individual might hesitate to communicate because they are intimidated, do not wish to bother or offend the more senior colleague, or do not want to appear incompetent (this is referred to as an authority gradient effect; Chapter 28) (19). Communication can also break down because lack of clarity about assigned roles leads to ambiguity or conflict. In a one-week study of a North American ED, 1,935 patient encounters generated 400 error reports (18 per 100 patients) (20). Forty-three errors (12%) were categorized as communication failures and included difficulties contacting the appropriate person and miscommunication between ED staff. Minimal contextual information was available to further refine the data, and other error categories might have included communication problems. For example, an adverse event categorized as a diagnostic study error was caused by a delay in the receipt of antiepileptic drug levels, which also represents a breakdown in effective communication channels. In a recent study of emergency medicine cases referred for morbidity and mortality review, teamwork failure was noted in 61% of cases, most commonly involving miscommunication and poor team transitions (21). Some insights into communication-related adverse events come from other clinical settings. In a review of 444 surgical malpractice claims resulting in actual harm to patients, 60 cases (13%) involving 81 communication breakdowns were identified (22). The majority of communication breakdowns were verbal (73%) and involved just two individuals (64%). The study identified status asymmetry between the communicating parties (74%) and ambiguity about responsibilities (73%) as commonly associated factors. Of particular relevance to the ED, 43% of communication breakdowns occurred with handoffs and 39% with transfers in patient location. The most common breakdowns involved attending-to-attending handoffs and residents failing to notify attending surgeons of critical events. One of the current paradigms in patient safety research is to undertake a linear root cause analysis to determine the causes of specific incidents with the potential for patient harm. Direct chains of causation can be difficult to identify, especially with communication-related errors. Interacting causes of the event are not easily open to inspection or introspection. Specifically, the high communication loads seen in some ED settings, with high multitasking and interruption rates, might be better understood by conceiving of the ED as a complex system in which error is an emergent property of multiple interacting events. No one thing “causes” the error. For example, one could model the ED as a toxic environment where individual clinicians are stressed by high communication loads and commit errors on tasks unrelated to communication. Clinicians, like all human beings, have finite cognitive resources. When individuals are busy and multitasking, resources such as working memory, which can be thought of as a short scratch pad for the mental to-do list of individuals, are typically full. An interruption by a colleague under such circumstances can cause an individual to forget

items in working memory, leading to errors such as forgetting to complete or initiate tasks, or to repeat tasks such as administer a medication, because they don’t recall having already done so (23).

IMPROVING COMMUNICATION PRACTICES IN THE EMERGENCY CARE SETTING Improving communication practices and outcomes typically involves an analysis of communication patterns at a very local level. Although general patterns are identifiable (such as high interruption rates), the specific interventions contemplated to improve communication will have to adapt to the specific circumstances of any organization. It is perhaps natural to consider a technological solution to improving team and departmentwide communication; however, it is more likely that interventions targeted at improving communication awareness, policy, and practice will yield more immediate results. Interventions that involve technology might show great promise, but they need to be targeted to specific communication problems. They usually require a period of organizational analysis, followed by time for implementation and evaluation.

STANDARDIZING THE CONTENT AND FORMAT OF COMMUNICATIONS In 2006, the National Patient Safety Goals of the U.S. Joint Commission on Accreditation of Healthcare Organizations included a requirement that institutions implement a standardized approach to patient handoffs (22). A majority (71.6%) of U.S. ED training program directors in a 2007 survey agreed that specific practice parameters regarding transfer of care in the ED would improve patient care, and 72.3% agreed that a standardized sign-out system in the ED would improve communication and reduce medical error (14). However, only 25.6% of programs indicated that they had formal didactic sessions focused on sign-outs. This variability in information transfer at handoff has also been identified in other settings, such as internal medicine (12). Barriers to effective handoffs include the physical setting (amount of noise, visual distractions), the social setting (interruptions, hierarchy), language barriers (dialects and subspecialty differences in terminology), and channels of communication (synchronous vs. asynchronous) (13). There clearly is a great opportunity to improve communication through educational programs and other interventions that standardize the process of communication. Such standardization can apply to written or verbal communication and can take several different forms. • Communication triggers: A common mechanism for minimizing breakdowns in communication in the aerospace industry is to develop standard communication protocols that are triggered in recognized safety-critical circumstances. For example, the two challenge rule states that a subordinate is empowered to take control if a pilot is clearly challenged twice about an unsafe situation and offers no satisfactory reply (11). Use of a list of triggers mandating communication can lead to improvements in communication and, consequently, in patient safety. For example, it is common practice to include in

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postoperative orders the abnormal vital signs or other parameters for which a physician should be notified. Examples of such triggers for communication with the surgeon currently responsible for a patient include changes in the location of the patient (transfer, admission, or discharge), a serious event (unplanned intubation, cardiac arrest, unplanned blood transfusion, or medication error) and staff concerns (22). Such triggers clearly have corollaries in the ED and might also be helpful in the setting of diagnostic or therapeutic uncertainty (10). A formalized policy that sets out specific event triggers for communication between ED clinical staff might lead to significant patient safety improvements.

unique character of the ED. Although it is always beguiling to implement tools found elsewhere to suit our specific needs, experience often teaches that such solutions are difficult to transfer to new settings and that developers often underestimate the complexity and cost of building systems. We should expect that the types of technologies available to the ED, and the manner in which they are applied, will constantly evolve. Some recent experiences with ICT–supporting communication in the ED are worth summarizing. The following sections provide some insight into the way ICT can help reshape communication.

• Read-backs: It has also been suggested that the use of standard read-back protocols might minimize the misinterpretation of communicated information between two parties (22). For example, clinicians can read back the information they have been told at a handover to confirm they have received and understood the information. • Standardized sign-out templates: Written sign-out information can be presented in a predefined structure. This might include critical fields that need to be filled out, e.g., the “code” or resuscitation status of a patient, pending results, and active problems requiring attention. • Computerized sign-out: Information technology has a role to play in improving the structuring and transmission of standardized information to improve team communication at critical events such as patient handoffs. A randomized controlled trial of one computerized rounding and sign-out system halved the number of patients missed on resident rounds and improved allocation of time to clinical tasks with residents spending 40% more of their preround time seeing patients (24). • Structured goals: Use of a structured daily goals form in the intensive care unit (ICU) produced a significant improvement in the percent of residents and nurses who understood the goals of care for the day and reduced ICU length of stay (25). At baseline, less than 10% of residents and nurses in the study understood the goals of care for the day. After implementing the daily goals form, greater than 95% of nurses and residents understood the goals of care for the day. After implementation of the daily goals form, ICU length of stay decreased from a mean of 2.2 days to 1.1 days.

Trauma cases create specific communication challenges to ED teams, as the team members are not always all at the same location. Some are in the field stabilizing and transporting patients; others are in the hospital preparing their units to accept the cases as well as providing guidance to the field. During catastrophic events, trauma teams might need to navigate a difficult communication environment, and the civil mobile telephone network might be swamped by the public. Consequently, communication channels between the field and the hospital base might need to rely on multiple, redundant systems. The hospital itself might utilize very different communication mechanisms to alert, assemble, and coordinate clinical teams. A recent investigation of the type and frequency of use of ICT to activate and organize trauma teams in level I and II trauma centers in the United States found that the majority of field communications with prehospital care providers took place through shortwave radio (67.3%) and that mobile or cellular (including satellite) phone (32.7%) and regular telephone (32.3%) were the next most frequently used devices (26). Most trauma centers (76.4%) alerted trauma team members of an incoming patient using a computerized group page. Regular telephone (70.1%) was used mainly to notify the operating room staff of impending surgery. Trauma surgeons were most often contacted by manual page (56.7%), regular telephone (39.4%), and computerized group page (36.6%). Computerized group page (53.7%) and regular telephone (49.8%) were cited as the most advantageous; e-mail (52.3%) and dry-erase whiteboard (52.1%) were selected as the least advantageous. The use of shortwave radio in addition to mobile phone in this survey might reflect the risks associated with total dependence on the mobile phone network. The reluctance in this circumstance to use asynchronous channels to assemble teams might reflect a synchronous bias among clinical teams when there is urgency in their tasks and a need to see that messages have been received and information acknowledged (5). We should not interpret these results as suggesting that asynchronous channels have no role in the ED, but that for the initial component of preparation and response, rapid action will typically drive a bias towards synchronous communication.

USE OF COMMUNICATION AND COMPUTER TECHNOLOGIES TO SUPPORT SAFER PRACTICE Information and communication technology (ICT) provides a broad set of tools to support communication and effective team interaction. Although there has been a longstanding interest in health care in the role of structured information systems such as the electronic patient record and administrative systems, the challenges of communication typically require the use of a different cluster of technologies. Asynchronous communication can be supported by whiteboards, e-mail, and task lists. Synchronous communication can be supported by portable communication devices, video consultation, and real-time information sharing across collaborative workspaces. Many of these technical options come ready-made from the consumer market. Others require significant design and investment to customize them to individual organizations or the

Trauma Coordination

Whiteboards Some asynchronous communication channels, such as e-mail, allow for noninterruptive communication at a distance. Others, like whiteboards, support asynchronous communication among team members who are physically co-located, but who might be separated in time. A core attribute of whiteboards (electronic or

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not) is that they are a relatively informal medium, meaning that the tool does not impose its own structure on the messages that it conveys. Compare the affordances offered by a whiteboard, for example, to that by an electronic form that imposes an external structure on which data are to be captured and where they must go. Informal tools can be adapted to a wide variety of tasks and can support the building of a shared understanding about the state of the world by those who share it (15). Whiteboards have been suggested as a means of improving team communication and reducing interruption (5). One recent uncontrolled case study provides some evidence that there might be reduced interruption rates in the ED when an electronic whiteboard is present—there were lower interruption rates in direct patient care tasks, and physicians were able to perform more tasks (27). Whiteboards in the ED or trauma center are usually centrally placed and can be viewed by a broad range of staff. Whiteboards might be used to capture general information and announcements, track patients’ movements through the system, hold information about staff assignments, and replicate schedules such as operating room times. Whiteboards might be richly annotated beyond what is written on them; for example, magnetic strips might designate individuals, and colors might represent specific information about the individual’s role (28). Paper is sometimes appended to the board underneath these magnets, for example, a paper form with patient details intended to be picked up when a patient is transported. In this way, whiteboards can become complex communication centers with multiple levels of structure and function. They enhance communication, permit situational awareness, and support complex acts of distributed cognition, such as schedule negotiations and joint planning (28–30). Concerns exist in some settings where the public is also able to view content on the whiteboard, raising issues of patient privacy. Thought must be given to the physical placement of such powerful coordinating media so that privacy constraints do not impede the free exchange of information for which they are so well suited.

Unanticipated Consequences It is important to note that the use of technologically mediated communication channels can result in unanticipated negative consequences (31). For example, it is a common misconception that transmission of a message by an asynchronous medium such as e-mail or “texting” by short message services constitutes effective communication, but such approaches do not guarantee that the transmitted message is actually received. In one study in which emergency laboratory results were communicated electronically instead of by telephone, 45% of the results went unchecked (32). In circumstances where information is critically significant, it might therefore remain good practice to confirm that sent messages have been received and acted upon. Indeed, safe practice dictates that simply sending a message does not discharge an individual from the obligation to the patient or the receiving party.

CONCLUSION There is a clear connection between effective team communication and patient safety in the ED. It is not simply that individuals must be clear about what they are saying to each

other. The mixture of high communication loads, interruptions, and multitasking typical of the ED provides an additional layer of risk to clinical practice and can be an indirect and silent contributor to adverse events. Improving team communication requires close attention to the specific nature of the organizations and clinical services involved. Local conditions are likely to have subtle but important consequences for any intervention intended to improve communication. Although there are clear opportunities that arise from the innovative adoption of information and communication technologies to make team communication safer, it is crucial not to ignore simple nontechnical interventions capable of being widely adopted and well understood by clinical teams, such as education and the establishment of simple and effective processes and procedures.

SUMMARY

Communication failures are a common contributor to adverse events. Emergency medicine practice might be particularly vulnerable to communication failure because of its fastpaced, interruption-driven environment. Communication systems comprise many components, including people, the messages they exchange, the technology they use, and the organizational structure in which they work. Communication in the ED is particularly important at transitions in patient care. Common communication failures occur when there is a difference in professional stature or seniority between individuals and when there is ambiguity about responsibility or roles. Suggestions for improving communication in the ED include the following: • Developing standardized approaches to communication processes, such as patient handovers • Developing specific communication protocols, particularly for safety-critical moments, such as the two challenge rule • Designating communication triggers that promote notification of physicians about potentially significant events • Encouraging read-back protocols Although innovations in information and communication technology offer new methods of communication, simple nontechnical interventions can be useful as well. Awareness of the importance of communication in assuring quality care is an essential step in driving safer processes.

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