FOREWORD: Communication Between Health Care Providers During Shift Changes in the Emergency Department

The emergency department (ED) is a facility where patients come in for assistance by themselves or that of an ambulance. Patients come extensively throughout the whole entire day needing immediate care. Saying this, it can get very hectic and communication from healthcare provider to provider gets very difficult and complex during their shift as well as handoffs. Handoffs are an exchange of information that goes from one doctor to another. These handoffs are key components to successful medical treatments. When physicians go from patient to patient, they need a physician to tell the background of the patient, the tests they have run, and the possible solutions for physicians to give the patient the best care that they possibly can. If the communication is not fully there, the physicians can run tests they have already done, misdiagnose the patient, or give them unnecessary treatment that they have already received. Writing down information on patients charts is not enough for the physician taking over that patient. They need face to face communication to get the full detailed analyzes about the patient to make sure there is no miscommunication on the chart.

When working in the emergency department, clinicians have to have patience throughout the chaos to stop and take a few minutes to communicate with their fellow healthcare providers. According to Sullivan (2013), the main cause of medical errors goes back to the lack of shared information between health professionals. Poor communication within the emergency department leads to thousands of medical errors that could turn into deaths if not careful. While the emergency department is frenetic with patients coming in and out and physicians running around, communication varies with the situation. In Welch, Cheung, Apker, and Patterson (2013), the researchers say that there are three communication modes in the emergency department: verbal, written, and visual signal. Verbal communication is quick and efficient to get a clear understanding of the patient that the doctors have. In addition, doctors can offer feedback with verbal communication, and they can ask questions if needed. This communication can be seen through face-to-face communication, pagers, voice mail, and a secure cell phone. Written communication is critical in health care because it goes on a permanent record. This type of communication can be broad by writing down on electronic files, and multiple staff members can view the records all at once. Having the emergency department as hectic as it is, writing down information is more effective in the matter of being able to go back and review the information about a patient. Written communication can be viewed in medical records, text messages, max messages, or even e-mail communication. Lastly, there is visual communication. This type of communication is not used as often as the other two, but people can observe this type of delivery through passing charts around, flag on a patients chart, or even having a light over a patient’s room to have them priority (Welch et al., 2013). These communication modes can help tremendously in the emergency department by getting the little details right in order for the patients’ case to be successful.

Although healthcare providers do have miscommunication, there are many factors that contribute to this lack of communication. In Yealy’s (2010) view, he believes poor handoffs can be connected to the “provider, team, task, technology, or the local or institutional environment.” Yealy is a professor and Chair of Emergency Medicine at the University of Pittsburgh that feels provider’s miscommunication can come from poor memory, inexperience, stress, and cognitive bias. Kendra Cherry (2018), an author and educator, describes a cognitive bias is often a major cause to medical error. She goes on by saying this is a type of error in thinking that occurs when people are processing and interpreting information in the world around them. The human brain is powerful but subject to limitations. Cognitive biases are often a result of your brain’s attempt to simply information processing.

Some factors that contribute to the team are peer relationship, recognize the importance of handoffs, and compensation methods. Despite the many advances in technology, it is still highly unreliable and can crash in a matter of seconds. With this being said, electronic health records are not always the best choice of option.

Miscommunication is a huge problem in emergency department cases. There are substantially high error rates which leads to serious consequences. Communication errors tend to be the root of 70% of cases’ failure. As stated in Yealy’s (2012) article, 84% of treatment setback was found to be caused by miscommunication. An interview was conducted to identify factors that made communication delay and the relationship between those factors. The interview came to show that there are three communication issues: experiential parameter, interpersonal parameter, and contextual factors. Every area within these communication issues showed that there are deviations in medical record keepings, pressure on clinicians, and lack of focus on relation skills (Pun, Matthiessen, Murray, & D, 2015). The researchers say that hospitals should implement programs that focus on the understanding of the miscommunication, acknowledging that the care is centered around the patient, implant clear knowledge of procedures, and lower the clinician-to-patient ratio to make communication more successful (Pun et al., 2015).

Researchers have found numerous ways to have smooth and effective handoffs. Researchers understand that the emergency department is very hectic and it can be difficult to have an effective conversation with other healthcare providers about the patient’s well-being. Dingley is a professor at the University of Nevada who wrote an article that explains simple communication tricks which he called SBAR: situation, background, assessment, and recommendation. The situation is what is going on with the patient, the background is an explanation of the clinical history and context of the patient, assessment is an explanation of the problem, and lastly, the recommendation is what they think needs to be done for the patient (Dingley, Daughterty, Derieg, Persing, 2011).

In Wald’s (2011) book, he introduces tips and ideas for medical students during shift changes in the emergency department. David Wald is a professor at Temple University that teaches emergency medicine. Some tips he gives are to be on time for the clinical shift, complete patient-related tasks before the physicians shift ends, and the list goes on and on (Wald, 2011). These tips for a successful shift change make it easier for the upcoming healthcare provider to transition into their shift with fewer questions or uncertainties. Making smooth transitions requires in-depth communication about the patient’s needs. In addition to smooth transitions, Yealy’s (2010) article provides four stages of care transition which include preturnover, arrival, meeting, and post-turnover. The preturnover time is when the time healthcare providers prepare for the upcoming shift change, the arrival is the beginning of a new shift, the meeting is the time in which there is an exchange of information regarding the patients, and the post-turnover time is when the healthcare providers focus on unfinished business and clarify complex information (Yealy, 2010). Although these are time-consuming tasks, they reduce the risk of medical errors due to miscommunication.

In addition to communication being challenging in the emergency department, there are patients that come in who do not speak English, making communication for healthcare providers even more complex. In the emergency department, it can take a half hour or longer to get a translator which must occur before the physicians can actually do their job. This communication barrier can lead to medical errors as well as the frustration of the patient and doctor. With this department being so hectic and complex without this barrier, there needs to be more access to translators so that patients are not waiting around in unbearable pain. Amy Norton, a health news writer, did research with her team on 57 primary Spanish-speaking families. Her results were astonishing; only 20 of these families had professional help from an interpreter, 27 families had no professional help, and 10 families had no translation help whatsoever. Lead researcher, Dr. Flores, pointed out in a report from the White House Office of Management and Budget that it would cost nearly “$268 million per year to offer interpreter services at hospitals and outpatient doctor and dentist visits” (Norton, 2012). Even though having interpreters would cost the government a lot of money, it could end up saving money in the end by having fewer medical errors.

The patients and clinicians also play an important role in communication throughout the emergency department. Yealy (2010) notes the factors that can contribute to patient communication are alertness, education, pain, language barrier, knowledge of own illness, and unclear diagnosis. If the patient comes into the ED and gives the doctors a false diagnosis thinking that it was right, it can make the process of their stay in the ED a lot harder and longer.

Moreover, the emergency department can be an extremely noisy environment which leads to stress in the healthcare providers and the patients themselves. Staff voices and medical machinery produces a lot of noise throughout the emergency department. On top of that, Welch, Cheung, Apker, and Patterson (2013) provide an article listing numerous objects that are noisy in the ED. Some examples are patient’s voices, paging machines, x-ray machines, telephones, in addition to many others. A noisy ED is not safe for the patient or the physician working. High levels of noise can lead to patients having a rise in blood pressure, increased heart rate, and loss of sleep. In the ED, communication and teachings have seemed to be impacted by the noise levels. Due to the level of noise, it is a good choice to have technology-based communication. When healthcare providers work in a noisy atmosphere, having clear communication is a lot harder than a normal quiet room. Welch et al. (2013) concludes that the “best results will be seen when process improvement, technology, and environmental design come together in this work.”

As can be seen, communication throughout the emergency department is one of the most important responsibilities during a physician’s shift. Any slight miscommunication may lead to a medical error or worse. Some hospitals put in place a communication system to help avoid errors of miscommunication however the errors of miscommunication still happen. To illustrate this, several articles were written by fellow UNC students who shadowed doctors last year expressing these same issues. Healthcare professionals need to go in depth and ask as many questions as needed to make sure the oncoming healthcare provider knows the status of the patient and is aware of what has to be done to get the patient the best care possible.