Simple strategies can be used in the ED

Emergency departments (EDs) can improve communication and patient care with simple strategies, says Gregory Cuculino, MD, an emergency physician at Taylor Hospital in Philadelphia.

Taylor Hospital uses physician-patient huddles, during which key elements of the patient's course are reviewed and any potential questions clarified. This communication is particularly important at the time of disposition of the patient, as the decision to admit or discharge often depends on clinical details of which the physician making that decision might not be aware, he says.

"The huddles help us get back to the kind of medicine we practiced years ago, when you actually had a few minutes to talk to each other," Cuculino says. "We do huddles at different points in the patient's care, including discharge huddles where the nurse can be the patient's advocate and tell us the patient still has a fever or doesn't have prescription medicine coverage. They can tell us these things then instead of me sending the patient home and then saying, 'Oops, wish I'd known that before I discharged him.'"

Implementing a trigger alert system at Beth Israel Deaconess Medical Center in Boston cut the time to initial physician contact and the mean time to the first therapeutic intervention by half, Cuculino says.

Dana Siegal, RN, CPHRM, director of patient safety services with CRICO Strategies, which organized the recent collaborative effort to devise ED strategies, says one participant institution is implementing a huddle at the time of the admission, using the mnemonic STOP: Significant issues, Therapies, Oxygen and last vital signs, and Pending issues. This communication is designed to identify any pending issues that could be missed as the patient transitions from the ED to the inpatient wards, she says.

Others have included a structured update between the charge nurse and the attending physician at key points in the shift to review the department as a whole and to identify any potential issues that might have arisen during the shift, Siegal says. "Many leaders from EDs with robust electronic patient tracking and charting systems noted that much of the MD-RN communication occurs electronically and emphasized the need to supplement electronic information with structured times for closed-loop verbal communication," she says.

Triggers can improve patient care

A vital sign trigger program is in use by ED clinicians at Beth Israel Deaconess Medical Center in Boston to more effectively assess the patients coming to the ED and triage them, says Carrie Tibbles, MD, an emergency physician and associate director of graduate medical education at Beth Israel, who co-chaired the ED strategy effort. It was developed by Clinical Operations Director Leon Sanchez, MD.

"The triggers program takes some of the subjective guesswork out and tells us that if a person has these vital signs, they need to be seen by a physician right away," she explains. "We have parameters for heart rate, respiratory rate, blood pressure, low oxygen saturation, marked nursing concern, and altered mental status."

The ED staff try to leave a couple of exam rooms in the more acute care area open for trigger cases, and a care team is summoned with the announcement "Trigger to Room 1," for example. "Instead of waiting to bring the patient back and then going to find a physician, by triggering the patient, the physician, nurse, tech and resident can meet in the room to quickly assess the patient," Tibbles says. "We've found that the time of the physician to bedside, the time to first intervention and the time to the intensive care unit are all faster if you use this system."


Gregory Cuculino, MD, Chairman of the Department of Emergency Medicine, Taylor Hospital, Telephone number: (610) 595-6458.

Carrie Tibbles, MD, Associate Director of Graduate Medical Education, Beth Israel Deaconess Medical Center, Boston. Telephone: (781) 439-8300. E-mail: