Strategies boost ED communication

Provider participants in the collaboration organized by Crico Strategies concluded that optimal physician-nurse communication at critical junctures in ED care are key to reducing diagnosis-related errors. They listed these key areas of information and/or vulnerabilities affecting information exchange that most often contribute to diagnostic errors in the ED:

• the availability of prior historical information from the medical record or referring physician;

• changes in patient status and/or unresolved abnormal vital signs;

• the timeliness of laboratory or radiology data;

• communication from the consulting physician;

handoffs;

• barriers to effective communication between the nurse and physician caring for the patient.

The participating hospitals determined that structured communication events, which provide specific prompts or events during the patient's ED visit, facilitate the communications of critical issues and information. These are some of the strategies they developed:

• Physician-nurse huddle. This conversation takes place at a defined moment in the patient's care to review key information or at regularly scheduled intervals during the shift.

• Triggers. The triage or primary nurse, or an ED assistant, is the first to know of an abnormal vital sign or change in the patient's status. A trigger system sets specific physiologic parameters that trigger an alert to the nurse and physician to respond to an unstable patient. Examples include marked tachycardia/bradycardia, hypotension, increased/decreased respiratory rate, hypoxia, or a nursing concern.

• Discharge timeout. Children's Hospital in Boston implemented a coordinated discharge process that includes a review of all patient information by the physician and nurse prior to discharge, sharing that idea with the other participating hospitals. Preliminary data demonstrate that many near misses have been identified and remedied before discharge of the patient.

• Reconciliation of abnormal vital signs. A frequent theme in medical malpractice cases is the discharge of a patient from the ED with persistently abnormal vital signs. One of the most important pieces of information to relay to the physician at the time of discharge is a persistently abnormal vital sign, such as tachycardia despite intravenous fluid therapy. That vital sign might be the only indication of a patient at risk for an adverse event upon discharge.

• Operational and organizational change. Processes can be standardized as much as possible to eliminate errors, and unnecessary work that does not add value to patient care is eliminated.

• Staff development and education. Participating hospitals recommended simulation of critical incidents followed by debriefing and reflection. Simulation is of particular value in emergency medicine because the makeup of provider teams is rarely the same due to variable schedules, they said.