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Tuesday, May 16, 2006

ER Communications Systems

Emergency Room Communications

Synchronous communication (face-to-face or telephone conversations) accounted for almost 90% of communications traffic in one study of ER communications. This brings about problems of inducing clinical errors through disrupted memory process, overloaded short-tem memory because of the combination of interruptions, multitasking, and sheer volume of information that is often unwanted or irrelevant.

Efficacy of communication systems is also a problem: for example, senior personnel expects to be paged twice 'if it really is an emergency', resulting in higher levels of communication, and further time-wasting. Vincent and Wears quote an earlier study, decribing that, "despite their own disinclination to be interrupted, clinicians often initiate communication or request information without any thought of the impact of their request on the other person. This is a form of suboptimisation, in which trying to increase one's own performance results in a net decrement in performance over the entire organization."

Reference
Communication in the Emergency Department: separating the signal from the noise
Charles A Vincent and Robert L Wears
MJA 2002; 176 (9): 409-410

Communication channels in the ER

- Face-to-face
- Telephone
- Pager
- Computer
- Patient's medical record
- Forms
- Medical literature
- Test results
- Drug manual
- Letter
- Whiteboard
- Email

Communication Typologies
- Formal communication: When a message conforms to a predetermined structure (ie, is in a predefined form).
- Informal communication: When the message structure is determined solely by the conversing parties.
- Synchronous communication: When two parties exchange messages across a communication channel at the same time (eg, telephone).
- Asynchronous communication: When communication exchange does not require both parties to be active in the conversation at the same time (eg, email). The recipient can deal with communication at a time of his or her choosing.
- Interruption: A communication event in which the subject did not initiate the conversation, and which used a synchronous communication channel.
- Multitasking: A period when two or more concurrent communication events occur.

Reference
Communication loads on clinical staff in the emergency department
Enrico W Coiera, Rohan A Jayasuriya, Jennifer Hardy, Aiveen Bannan and Max E C Thorpe MJA 2002; 176 (9): 415-418


In hospitals, response times are critical and efficacy of staff-to-staff communication and patient-staff communication is vital. What is on offer on the market gives pointers to market demands, which include:

Desirables
- Enabling hospital personnel to remain fully accessible at all times.
- Immediate access
- Not interfering with hospital wireless or electronic devices.
- Easy integration with existing systems
- Single-number solutions that integrates all existing systems and numbers.


Categories
- Hospital televisions - MATV & RF Distribution
- On-demand education/information systems
- Satellite systems - entertainment, teleconferences, and programming packages
- Nurse call systems, intercom and overhead paging
- Infant abduction and patient wandering
- Access control systems
- CCTV surveillance/security systems
- In-building wireless phone systems
- Service and maintenance

Hospital personnel-Patient communication systems

- Constant contact with patient care providers, beginning from the ambulance parking lot, Enabling nursing staff to receive instant text messages through integration with nurse calls systems.
- Allowing the nursing staff to conduct initial assessment of a patient’s needs while consulting with a physician, remotely.
- Enabling the physician to consult with specialists in a ‘hands-free’ mode
- Providing family members of acutely ill patients a way to remain in close contact with hospital staff
- Permitting maintenance and security personnel to receive critical alarm and security notification via text messaging
- Accelerates access to mobile hospital staff via networking of multiple locations
Implements an effective disaster recovery solution that supports and maintains communication.


Reference
Ascom Wireless Solutions (http://www.hospcom.com/Hospcompdfs/04-PRIVATEWIRELESSPHONESYS/01%20-%20TIME%20IS%20CRITICAL.pdf)

Issues/questions?
- Is text messaging as the best means of communication within the ER and between hospital departments?
- How else can we transmit this data in a less cumbersome, more instantanaeous way? Special ER/treatment related symbols on a handset? Conventional video-confereing via cellphone? Are unita by the bedside with hands-free access for instant communication better than pager systems?


Emergency Communication Systems
- Patient emergencies
- Disorderly patients
- Wandering patients
- Code blue teams
- ED
- Chemical/Hazardous material environments

Need
An automatic system to ensure quick response times.


Process
- Automatic / user-initiated control to raise alarm.
- Notification, escalation and routing of distress signals to pre-defined team members .
- Discussion of situation via group call.
o Identify the nature of the emergency situation
o Talk to the initator of the emergency
o Ensure proper equipment and personnel are identified and gathered simultaneously
o Discuss estimated arrival times and team member proximity to emergency
o other team members can be notified by text message
- Reaction: fast and coordinated.


Reference
http://www.hospcom.com/Hospcompdfs/04-PRIVATEWIRELESSPHONESYS/12%20-%20EMERGENCY%20NOTIFICATION%20SOLUTION.pdf



One Australian study attempted to address the problem that few studies of communication between healthcare professionals exist, observing
- Time involved in communication
- number of communication events
- interruptions, and overlapping communications
- choice of communication channel
- purpose of communication
between 12 clinical staff members, comprising six nurses and six doctors in two emergency departments, one 200 bed rural hospital and one 540-bed urban tertiary teaching hospital, in New South Wales hospitals, in 1999.

“5 hours and 13 minutes were observed, and 1286 distinct communication events were identified, representing 36.5 events per person per hour (95% CI, 34.5–38.5). A third of communication events (30.6%) were classified as interruptions, giving a rate of 11.15 interruptions per hour for all subjects; 10% of communication time involved two or more concurrent conversations; and 12.7% of all events involved formal information sources such as patients' medical records. Face-to-face conversation accounted for 82%. While medical staff asked for information slightly less frequently than nursing staff (25.4% v 30.9%), they received information much less frequently (6.6% v 16.2%).

Their conclusion supports the “need for communication training in emergency departments and other similar workplaces. The combination of interruptions and multiple concurrent tasks may produce clinical errors by disrupting memory processes. About 90% of the information transactions observed involved interpersonal exchanges rather than interaction with formal information sources..”

“Several studies quantifying the impact of poor communication on clinical work suggest that communication is a likely cause of systematic error in the health system. In Australia, inadequate communication has been associated with 17% of system problems, and, of these, 84% were deemed potentially preventable.1 About 50% of all adverse events detected by general practitioners were associated with communication difficulties.2 Within intensive care units, 2% of the activity consists of verbal communication between nurses and doctors, but accounts for 37% of error reports.3 Thus, the evidence strongly suggests that poor communication wastes time, threatens patient care and may be one of the chief culprits behind preventable adverse events in clinical practice.4
The research reported here extends work begun in the United Kingdom in the mid-1990s,5,6 in which it was found that physician teams in hospital were subject to high levels of interruption. Clinical staff also appeared to bear a higher communication load than necessary, considering the many tasks that could be accomplished by accessing information sources rather than asking questions of people. It has since been hypothesised that such interruptions impose cognitive loads on clinical staff and have a negative impact on memory, leading to clinical error.7”

The following points I found of most interest:
- Nearly a third of communication events were classified as interruptions,: that they were not initiated by the observed subject, and occurred using a synchronous communication channel such as face-to-face conversation.
- Subjects were carrying out two or more overlapping conversations (multitasking) for 10% of the total communication time.
- About 90% of the information transactions observed involved interpersonal exchanges rather than interaction with formal information sources. (Their conclusion being that this suggests a low upper limit on the potential for electronic medical records (EMRs) to improve information processes within healthcare organizations, since the EMR is essentially a formal medium.)


Purpose of communication events in the emergency department





Communication events are expressed as a proportion of all communication events, by clinical role (NOS = not otherwise specified)


Reference Communication loads on clinical staff in the emergency department
Enrico W Coiera, Rohan A Jayasuriya, Jennifer Hardy, Aiveen Bannan and Max E C Thorpe MJA 2002; 176 (9): 415-418
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Alexandra Ginsberg at 6:07 AM

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