The role of teamwork and communication in the emergency department: A systematic review

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Abstract

The aim of this study was to develop a systematic review using international research to describe the role of teamwork and communication in the emergency department, and its relevance to physiotherapy practice in the emergency department. Searches were conducted of CINAHL, Academic Search Premier, Scopus, Cochrane, PEDro, Medline, Embase, Amed and PubMed. Selection criteria included full-text English language research papers related to teamwork and/or communication based directly in the emergency department, involvement of any profession in the emergency department, publication in peer-reviewed journals, and related to adult emergency services. Studies were appraised using a validated critical appraisal tool. Fourteen eligible studies, all of mid-range quality, were identified. They demonstrated high levels of staff satisfaction with teamwork training interventions and positive staff attitudes towards the importance of teamwork and communication. There is moderate evidence that the introduction of multidisciplinary teams to the ED may be successful in reducing access block, and physiotherapists may play a role in this. The need for teamwork and communication in the ED is paramount, and their roles are closely linked, with the common significant purposes of improving patient safety, reducing clinical errors, and reducing waiting times.

Introduction

In Australia and many other Western countries, the emergency department (ED) is potentially a unique environment for effective teamwork and communication. This needs to be explored in the context of the current ED system, and the dilemmas facing the modern ED need to be understood.

The traditional ED team consists of doctors and nurses only, however these practitioners work mainly independently due to conventional demarcations (Cronin and Wright, 2005). The practitioner has little control over the environment and the care delivery process is fragmented (Cronin and Wright, 2005). Work is often duplicated, for example patients could be asked to give their history a number of times to different staff members (Eisenberg et al., 2005). This autonomous work is time-consuming, in a workplace where there are already considerable time constraints, potentially causing inappropriately hasty decisions and unnecessary delays (Cronin and Wright, 2005). Also, to work independently is not efficient in an environment that is also characterised by multiple hand-overs between staff, frequent staff member substitution, uncontrolled workloads and high-risk diagnoses (Mercer et al., 2008). Staff sometimes need to deal with numerous patients with highly variable problems simultaneously (Eisenberg et al., 2005). There can be high levels of uncertainty due to incomplete patient histories and “...the need to make difficult decisions before critical data ... may be available” (Eisenberg et al., 2005, p. 391).

More recently, these problems have been compounded by the phenomenon of access block. Access block and overcrowding are the most serious issues confronting EDs worldwide (Forero and Hilman, 2008). In an Australian context, access block is defined as “…the percentage of ED patients who are admitted, transferred, or dying, whose total ED time exceeds eight hours” (Cameron, 2003, cited in Taylor et al., 2004, p. 683). Total attendances to Australian EDs have increased, and there has been a concurrent decrease in access to inpatient beds (Taylor et al., 2004). Other causes of access block include limited community-based treatments and service delivery issues such as insufficient hospital staff numbers (Cameron and Campbell, 2003). Also, shortage of aged-care places and lack of home support has increased the need to admit elderly patients, and this has been identified as the primary contributor to access block (Moss et al., 2002).

Taken together, the problems confronting traditional ED service and the more recent issue of access block contribute to the likelihood of errors in emergency care (Eisenberg et al., 2005). Effective teamwork can improve patient safety as it leads to planned and standardised processes, proper integration and execution of clinical activities, and increased control over the work environment (Kaissi et al., 2003). Studies have described the addition of a multidisciplinary team to the ED to address the ED service delivery issues (Moss et al., 2002, Taylor et al., 2004, Phillips et al., 2006). As collaboration amongst professions is necessary for the smooth conduct of the ED, such teams are becoming an essential component (Reddy and Spence, 2006). Morey et al. (2002) argue that a team is not a loosely coordinated group but has a more formal structure of physicians, nurses and technicians who are organised for a shift. Teamwork in the health care system may result in an increase in effectiveness, time efficiency, staff morale and patient satisfaction, as well as lower stress for staff and patients (Kaissi et al., 2003). However, the majority of current training in health care is focused on individual technical skills rather than teamwork (Kaissi et al., 2003). Therefore, this systematic review will explore possible options for staff training focused on teamwork.

Effective communication, which includes face-to-face conversations, telephone conversations and the entry of text into a medical record, is essential to successful teamwork and fundamental to high-quality patient care (Mercer et al., 2008). Research suggests that poor communication is a likely cause of systematic error and preventable adverse clinical outcomes in the health system (Coiera et al., 2002, Spencer et al., 2004). Communication errors have been shown to be the leading cause of in-hospital deaths in Australia (Woloshynowych et al., 2007). In the emergency department, communication between staff is often challenged by interruptions and high levels of background noise (Xiao et al., 2007). These problems, as well as the frequency of multi-tasking that occurs in the ED, impose cognitive loads on clinical staff that can negatively affect memory (Coiera et al., 2002, Woloshynowych et al., 2007). However, “despite the acknowledged importance of communication, assessment of communication skills in team-based care settings has not been well-established” (Mercer et al., 2008, p. 220).

Physiotherapists have recently joined the multidisciplinary teams in many hospitals internationally, but their role in the ED has not yet been well-documented (Anaf and Sheppard, 2007a, Anaf and Sheppard, 2007b). In an Australian context, the introduction of a physiotherapist to the ED team is very new, yet this service has been in place in UK hospitals for some time (Morris and Hawes, 1996, Kempson, 1996). This systematic review aims to set the scene for the integration of the physiotherapist into the Australian ED team by exploring current literature about teamwork amongst other health professionals. As poor teamwork and communication have been identified as possible causes of errors in the ED, this review seeks to investigate possible solutions to these problems.

This systematic review therefore considers the following question about the current available literature: What is the role of teamwork and communication in the emergency department, as reported in international literature, and how does this relate to physiotherapy practice in the emergency department?

Section snippets

Identification of literature

A systematic search of electronic databases was conducted in October 2008 to identify literature. There were no time limits placed on the search, as there is no previous systematic review in this area and the scope of available literature was unknown. The accessed databases were CINAHL, Academic Search Premier, Scopus, Cochrane, PEDro, Medline, Embase, Amed and PubMed. These included medical and social sciences subject areas. These databases were searched using keywords that were chosen based

Results

Initially, 20 studies were identified, yet six were excluded due to their anecdotal nature (Poulton and West, 1993, Patrick and Alba, 1994, Kelly, 2005, Seibens, 2005, Lynch and Cole, 2006, McKeon et al., 2006). Fourteen studies were found to meet the inclusion criteria. Before and after (n = 5) and descriptive case studies (n = 5) were the most common methodological approaches, and the latter included the one qualitative study identified. Other studies used a descriptive cross-sectional (n = 4)

Discussion

The literature suggests that teamwork and communication play a role in four main areas in the ED: improving patient satisfaction, improving staff satisfaction, reducing clinical errors and improving patient safety, and positively affecting access block.

The introductions of the CCT and RAPT teams to the ED lead to increased patient satisfaction and relieved patient stress, due to a number of reasons including decreased waiting time and the provision of reassurance (Moss et al., 2002, Cronin and

Conclusion

This systematic review confirms that the ED is a unique environment due to the volume of work and the need for accuracy under pressure. Teamwork and communication are paramount, but remain difficult to quantify. Their roles in the ED are closely linked, with the common significant purposes of improving patient safety, reducing clinical errors, addressing the issue of access of block and reducing waiting times. The findings of the literature should be viewed with caution given the methodological

Acknowledgement

Author would like to thank Dr. Sophie Anaf for contribution to the conduct of the systematic review.

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