The practice of emergency medicine/original research
Communication Patterns in a UK Emergency Department

Presented at the Presentation of Results Day: Ethnographic Research, NPSA, September 2005, London, England.
https://doi.org/10.1016/j.annemergmed.2007.08.001Get rights and content

Study objective

Good communication is important in patient care and plays an essential part of teamwork and patient safety. Communication in the emergency department (ED) can be chaotic, with the potential for error resulting from communication overload and problems of communication. The nurse in charge of the ED plays a crucial role in maintaining communication flow. The aims of this study are to identify the features of the communication load on the nurse in charge of the ED.

Methods

This was an observational, nonexperimental study, building on the methods of observation and analysis developed by Coiera. It was carried out in an inner-city hospital ED in London. The nurse in charge of the ED was observed. The following factors were studied: the level of communication, interruptions, and simultaneous events; the channel and purpose of communication; interaction types; unresolved communications and annoying aspects of the observed periods; and the effect of weekday, staffing, and patient levels on the level of communication.

Results

Eleven nurses were observed during 18 observation periods during a total of 20 hours. Analysis revealed that there were 2,019 communication events in 20 hours and that 1,183 (59%) were initiated by the nurse in charge. Two hundred eighty-six (14%) simultaneous events/tasks were identified by the observer. One thousand five hundred twenty-eight (76%) communications involving the nurse in charge were face to face, 144 (7%) were by telephone, 107 (5%) concerned the use of the computer, and 104 (5%) concerned the use of the whiteboard. The largest purpose of communication events was related to patient management (48%). There was a slight relationship between junior medical staff and the level of communication and a moderate relationship between communication load and the number of patients in the ED. In addition, a greater number of nurses on duty were associated with fewer communication events with the nurse in charge.

Conclusion

These findings are an important measure of communication load, which can disrupt memory and lead to mistakes. Improving communication between health care staff by reducing the levels of interruptions and minimizing the volume of irrelevant or unnecessary information exchange could therefore have important implications for patient safety.

Introduction

Good communication between health care staff is a salient prerequisite to ensuring that complex clinical environments are run smoothly and efficiently.1 Poor communication among health care staff can substantially contribute to medical error.2, 3, 4 When information is not communicated effectively, this can impose adverse effects on the patient in terms of clinical outcomes.5, 6, 7 In Australia, a retrospective review of 14,000 inhospital deaths showed that communication errors were the lead cause and were held accountable for twice as many errors as inadequate clinical skill.8 Further, an incident monitoring study reported that communication problems were related to 50% of all adverse events.9

Interruptions in health care settings are ubiquitous. Findings from the United States and Australia have shown that interruptions in work processes are frequent, occurring on average 10 times per hour.10, 11, 12, 13 Furthermore, health care staff often have to deal with 2 or more tasks concurrently.11 These findings are of concern for 2 reasons. Interruptions can disrupt memory and generate errors14; multitasking may result in memory overload, causing some of the information to be lost before processing is complete.15

Communication in the emergency department (ED) can be chaotic, with potential for error resulting from communication overload and problems resulting from poor communication.10, 11 The ED has been described as an interrupt-driven environment,11, 12 leading to task change.12 In 2003, the Department of Health in England and Wales introduced a national target that 98% of patients who attend EDs will have completed their treatment and have left the department within 4 hours of arrival. This target has resulted in increased pressure to assess, investigate, treat, and either admit or discharge within this period and has the potential to increase the frequency of communication and hence interruptions.

The nurse in charge of the ED plays a crucial role in maintaining communication flow. This role is very demanding, and in one UK hospital where the nurses work 12-hour shifts, they take the role of “nurse in charge” for only half the shift, when they are responsible for the daily monitoring and management of patients and staff in the ED. The nurse in charge therefore has a pivotal role in ensuring the smooth functioning of this complex clinical environment. Thus, it is important to study levels and patterns of communication exchange in this particular staff group. Furthermore, other studies have examined the communication load of staff in the ED,16, 17 including the relationship between interruption rate and shift intensity, as measured by the time taken for the emergency physician to assess the patient since registration.17

In 2002, Coiera and Tombs,1 Coiera et al11, 18, 19 produced a method to measure communication patterns, based on previous research in the clinical environment. The method, known as the communication observation method, provides a validated observational method in which to measure the communication load of different health care staff.19 The communication observation method consists of the following components: subject observation, audio transcripts and field notes, events identified within the transcripts, coding event description, and analysis. Before and after the observation periods, the nurses are asked to clarify their role and any incomplete information arising during the observations, respectively.19

The primary aims of the present study were to use the communication observation method to investigate the communication load of the nurse in charge of the ED and to build on this method by collecting additional information that would help us to interpret the data, such as patient throughput and staffing levels.

Section snippets

Study Design

This is an observational, nonexperimental study design.

Setting

The setting for this study was an inner-city hospital ED in London, UK. The ED is classified as type 1, consultant led; is open every day, all day and night; and accepts all undifferentiated receiving ambulances. It responds to 85,000 adults, 22,000 children, and 6,000 reviews (ie, reevaluation of wounds) each year. The department also has a Clinical Decisions Unit for patients who require a longer period of observation before discharge or

Characteristics of Study Subjects

Eleven nurses in charge of an inner-city hospital ED were observed while they conducted their daily nursing activities. The sample comprised 2 men and 9 women of varying ages, ranging from 27 to 46 years (mean 33.78 years; SD 5.65 years). Nurses’ experience ranged from 4 to 11 years (mean 6.67; SD 2.11 years). Four of the nursing staff were observed more than once.

Data collection took place during a 6-month period (January to June 2005) on a typical weekday between 9 am and 6 pm. A total of 20

Limitations

Because of the pivotal role of the nurse in charge in ensuring the smooth and efficient running of the ED, the present study investigated the communication load, and to some extent the cognitive load, of this particular staff group. However, a limitation of this study is that the results cannot be generalized to other clinical staff groups (such as junior physicians or middle-grade physicians or even other registered nurses) in the ED. Although this was not the aim of the present study, it

Discussion

Our study showed that the nurses in charge of the ED had to deal with high levels of information exchange as part of their daily working activities, with a new communication event occurring on average every 0.59 minute (36 seconds), or 1.68 communication events every minute. This equates to 100 communication events per hour and is greater than that previously reported, eg, 36.5 events per hour.11

In accordance with previous research,11, 14 staff members in the ED seem to favor synchronous

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    Furthermore, the Danish study reported an association between work-related stressors and errors. The communication load is known to be high in the ED context and communication is one of the most common activities in the ED [3,21,46]. Communication breakdowns are common contributors to errors in health care [21,20].

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Supervising editors: Robert L. Wears, MD, MS; Michael L. Callaham, MD

Author contributions: CV secured the funding for this study. MW managed the project, including the supervision of data collection and analysis. RB facilitated access to the ED. RD collected and analyzed the data. All authors contributed to the monitoring the project and writing the article. MW 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 might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. UK NHS Patient Safety Research Programme funded the project.

Reprints not available from the authors.

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