Elsevier

Annals of Emergency Medicine

Volume 44, Issue 3, September 2004, Pages 268-273
Annals of Emergency Medicine

The practice of emergency medicine
Variation in communication loads on clinical staff in the emergency department,☆☆,

https://doi.org/10.1016/j.annemergmed.2004.04.006Get rights and content

Abstract

Study objective

We determine whether there are differences in role-related communication patterns in the emergency department (ED).

Methods

This was an observational study of a metropolitan ED. Four medical officers and 4 nurses were observed for 19 hours and 52 minutes. Communication load was measured by proportion of observed time in communication, proportion of concurrent communication events, and proportion of interruptions.

Results

Eight hundred thirty-one communication events were identified, an average of 42 events per person per hour. Eighty-nine percent of clinicians' time was spent in communication. Synchronous communication channels, involving face-to-face or telephone conversations, were used in 84% of events. One third of communication events were classified as interruptions, averaging 15 interruptions per person per hour. Senior medical and nursing staff experienced higher rates of interruption than junior medical staff and registered nurses with an allocated patient load.

Conclusion

There was considerable variation in communication loads on clinical staff occupying different roles in the ED. Medical registrars had a high proportion of interruptions and spent the most time dealing with interruptions. These new data suggest some clinical roles may be at higher risk of communication overload than those of the general clinical population.

Introduction

Communication failures in the health system have been reported to be a large contributor to preventable adverse clinical outcomes.1., 2. In the emergency department (ED), studies have demonstrated that clinicians experience high communication loads.3., 4. In situations in which individuals carry out multiple concurrent tasks, interruptions are seen as a source of concern because they may negatively affect a clinician's working memory and lead to errors.5 ED clinicians have been identified as being particularly at risk of communication overload, with reports that they may spend up to 80% of their time in communication, with 30% of all communication events classified as interruptions and 10% of the communication time involved in 2 or more concurrent conversations.4

Studies have repeatedly shown that clinicians prefer interaction with colleagues as the main method for answering clinical questions.3., 4., 6., 7. Examining communication patterns identifies which work practices are likely to be generators of high communication load, providing information to appropriately target interventions to support and improve communication practices in the ED.

If communication loads are associated with specific work patterns, then one would expect load to vary with clinical roles. The aim of this study was to determine whether there are differences in role-related communication patterns in an ED and to identify whether specific clinical roles are particularly at risk of high communication loads because communication overload may predispose clinicians to making errors.

Section snippets

Theoretical model of the problem

It has been hypothesized that interruptions impose cognitive loads on clinical staff, leading to clinical error.4 Specifically, when an individual's working memory is occupied with several items, an interruption may disrupt working memory, resulting in forgetting some items.5 Communication load is a measure of the impact of organizational process on individuals and indicates under which circumstances cognitive resources are likely to be stretched. We characterize communication load by the time

Characteristics of study subjects

The roles of the 8 clinicians were medical registrars (senior ED clinicians), junior physicians (intern and resident), nurse shift coordinators (senior nurses responsible for coordinating activities within the study ED, with no specific patient load), and nurses with an allocated patient load. Two subjects occupied each of these roles.

Main results

Total study observation time was 19 hours 52 minutes, in which 831 distinct communication events were identified, an average of 42 events per person per hour.

Limitations

The representativeness of the findings is limited by the small sample of subjects and shift times observed. Some roles were observed longer than others. In addition, the sampling did not capture all clinical roles found within the ED; for example, emergency consultants and triage nurses were not directly observed as the primary subject, although many clinicians were captured in the observations through their interactions with the primary subjects. Participants volunteered to be observed, which

Discussion

There was a wide variation in communication loads on clinical staff occupying different roles in the ED. Medical registrars had a high proportion of interruptions (on average, 47% of all communication events) and spent much of their time dealing with interruptions (on average, 35% of their communication time). These proportions are much higher than the ED population average of 36% of events classified as interruptions and 24% of communication time spent in interruptions, which on their own have

Acknowledgements

We thank the ED staff who generously gave their time to be involved in this study. Johanna Westbrook, PhD, kindly assisted in the analysis of the data.

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Author contributions: EC conceived the study and obtained research funding. All authors were involved in the study design. RS and PL conducted the research and analyzed the results. RS and EC drafted the manuscript, and all authors contributed to its revision. EC takes responsibility for the paper as a whole.

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Supported by a grant from the New South Wales Department of Health under the auspices of the Collaborative Projects Planning Committee.

Reprints not available from the authors.

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