The practice of emergency medicine/original research
Emergency Department Communication Links and Patterns

Presented as an abstract at the Society for Academic Emergency Medicine annual meeting, May 2006, San Francisco, CA; and the Industrial Engineering Research Conference, May 2006, Orlando, FL; and presented as a conference proceeding at the Systems and Information Engineering Design Symposium, April 2005, Charlottesville, VA; and the International Ergonomics Association annual meeting, July 2006, Maastricht, The Netherlands.
https://doi.org/10.1016/j.annemergmed.2007.03.005Get rights and content

Study objective

We characterize and describe the communication links and patterns between and within emergency department (ED) practitioner types.

Methods

This is a prospective, observational study of emergency physician and nursing staff communication patterns in an academic ED using link analysis techniques. Twenty ED staff members were observed in the pediatric and adult acute areas of the ED, including attending physicians, residents, nurses, and charge nurses. Data were recorded for each communication event, including duration, mode, partner, location, and interruptions. Because this study was intended to focus on professionally related communication between staff, social interactions and direct patient interactions were excluded. Frequency percentage and duration were calculated for each measure, and link analysis graphs were prepared to assist in interpretation of the data.

Results

One thousand six hundred sixty-five total communication events were recorded during a total of 39 hours 12 minutes of observation. Face-to-face communication was the most common mode. Communication links and patterns were described and graphically represented using a link analysis technique. Communication gaps were found between ambulance providers and the providers who would ultimately take care of the patient during their ED stay. Attending physicians communicated often despite caring for separate patients, and the charge nurse seemed to be the hub for communication, linking ED personnel with non-ED staff. In the adult area, interruption rates ranged from 6.9 per hour (attending physician) to 0.5 per hour (bedside nurse), and in the pediatric area they ranged from 3.6 per hour (attending physician) to 0.3 (bedside nurse).

Conclusion

Distinct patterns are identified. These results will be helpful in designing future communication adjuncts in the ED.

Introduction

Safe, efficient, and quality patient care in the emergency department (ED) requires frequent and effective communication between caregivers, yet little scientific data exist to characterize communication patterns in emergency medicine.

The importance of communication in the emergency medicine environment has been well documented,1, 2, 3, 4, 5 and potential problems and impediments to effective communication that are unique to this setting have been described.6, 7, 8, 9 Communication in the ED is achieved with several modalities, including verbal (face to face, telephone, radio), reading, and writing (whiteboard, patient chart, computer information systems), and plays a central role in key ED processes.5 Understanding how communication occurs in the ED is critical to the successful design of new technologies that will inevitably replace or augment current communication modalities in the future, such as electronic status boards, electronic medical records, and other communication instruments.

Safety engineering fields such as human factors engineering have long studied the way in which communication supports the coordination of activities and cognitive processes in event-driven complex domains such as space shuttle mission control and the nuclear industry.10, 11 These types of studies use a variety of methods to describe human activities, including task analysis techniques that focus on the observation and documentation of the content, location, and duration of specific task activities, including physical actions, decisionmaking, and problem solving activities, and communication.12

Although some task analysis studies in the medical domain have been published,13, 14, 15, 16 only a few have been focused specifically on emergency medicine.6, 17, 18, 19, 20 One technique for analyzing and representing output from a task analysis is a link analysis,12 which can show links among individuals according to the existence and frequency of their communication. This has been used previously in the medical domain but not to our knowledge in emergency medicine.14, 15, 21 A need exists to build on previous studies by documenting patterns of communication links among ED providers.

Despite the importance of interpersonal communication in the ED and the role it plays in safe, efficient, and effective care, few studies have attempted to document patterns of communication within EDs. Hollingsworth et al20 used time-motion methods to document activities of emergency medicine providers, including activities that were entirely or partially communication related, such as talking to patients, nurses, patient families, and other physicians, and highlighted the frequency of interruptions. Although they did not specifically classify interruptions by type, it appears from their discussion that a primary cause of interruptions in the ED was from communication events. However, this research was not focused on communication linkages across specific types of providers, frequency of communication events, or communication modes. Studies conducted in an Australian ED have analyzed communication modes and examined the differences in communication loads between provider types, but it is unclear whether practice cultures are similar enough to be generalizable to American EDs; additionally, these studies did not present a graphic link analysis of communication links among different provider types.22, 23, 24 Other studies of communication in EDs include a qualitative study that described critical communication processes involved in activities such as triage, handoff, and hospital admission, along with their role in ED decisionmaking and their potential for introducing or allowing vulnerabilities in the systems.5 For instance, this study noted that much of the communication about patient handoffs occurred within professional groups (eg, physician to physician, nurse to nurse) rather than across groups, and the lack of structured interaction between such groups could lead to problems in care. This study, however, did not focus on a quantitative documentation of communication pathways among providers. These studies have provided important groundwork in describing aspects of ED communication, and they support a need for research to explore the details of communication links between providers.

The goal of this study is to characterize and describe the communication links and patterns between and within practitioner types in a North American academic ED.

Section snippets

Study Design

This is a prospective, observational, task analysis study of emergency physician and nursing staff communication patterns in an academic ED.

Setting

Data collection took place during April and May 2005 at a university medical center ED that treated 93,350 patients (30% pediatric) in 2005 and is a 900-bed tertiary care regional trauma center hospital. Observations took place in 2 of 6 treatment areas, the 42-bed adult acute care (including a 7-bed trauma/critical care area), and the 19-bed pediatric

Results

Fifteen participants were observed during day shifts and 5 during evening shifts, each for approximately 2 hours. Stop times varied to avoid data collection through shift changes and breaks. One thousand six hundred sixty-five total communication events were recorded during a total of 39 hours 12 minutes of observation. A summary of results is provided in Table 1. After 89 personal or social events and 153 periods in which a provider interacted with a patient were excluded, a total of 1,423

Limitations

This study has limitations which are important to note. First, 20 participants were enrolled in the study, and because this included only 2 of each provider type in each area of the ED, it is possible that individual variation in communication styles affected results. However, because functional roles are so well defined and staff is task oriented and goal directed, we suspect that this had minimal effect.

This study was focused in 2 of 6 treatment areas in the ED (pediatric and adult acute).

Discussion

The purpose of this study was to use link analysis techniques to describe communication between roles in the ED, including who communicates with whom, what mode they use, and where the conversations are held. The results of this study will help us understand how to optimize communication in the ED, particularly when new methods are introduced, such as use of information technology solutions.

The methodology for this type of study is challenging because, short of providing every staff member,

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    Supervising editor: Robert L. Wears, MD, MS

    Author contributions: RJF and AMB conceived the study, designed the study, obtained research funding, and supervised the conduct of the study and data collection. RJF and MS undertook recruitment of ED staff member participants. MS performed all observations and entered the data. AMB and MS managed the data. All investigators participated in the analysis, and AMB provided statistical oversight. RJF drafted the article, and all authors contributed substantially to its revision. MS designed the figures and tables under the supervision of RJF and AMB. RJF takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that may create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Support was provided for this study by the Ronald McDonald House Children’s Charities Research Fund. At the time of the study, Dr. Bisantz and Ms. Sunm were partially supported by the National Science Foundation (grant no. IIE9984079); and Dr. Fairbanks, by the NIH (1R41NR009592) and AHRQ (1U18HS015818).

    Reprints not available from the authors.

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