Emergency Medicine in Clerkship

Effective communication between emergency medicine providers and nurses is crucial for patient safety and outcomes, as miscommunication is a leading cause of errors in fast-paced, high-stress environments like the emergency department.

Improving EM Provider and Nurse Communication

• Communicate Early Diagnostic and Disposition Plans
  • Recommendation: Share diagnostic assessments, care plans, and especially disposition plans early to allow team members to prepare.
  • Example: After assessing a chest pain patient, the physician updates the nurse on the plan, including the possibility of overnight observation.
  • Why: Early communication helps nurses begin discharge or admission preparations, reducing patient length of stay
• Share Pending Tasks and Updates
  • Recommendation: Regularly communicate pending tasks and inform of any delays or changes.
  • Example: A physician documents pending tests in the EHR, and the nurse proactively requests orders to proceed.
  • Why: Shared understanding helps detect errors or prevent delays in patient care.
• Communicate Proactive Testing and Interventions
  • Recommendation: Discuss diagnostic tests and interventions early.
  • Example: The nurse initiates a protocol after confirming with the physician about specific lab tests and procedures.
  • Why: Coordinated actions reduce delays in care and improve patient outcomes.
• Ensure Shared Understanding of Information
  • Recommendation: Don’t assume everyone knows the plan; communicate important details to all team members.
  • Example: An orthopedic consult informs the physician, but the nursing team remains unaware, causing a last-minute scramble.
  • Why: Ensuring all members have up-to-date information prevents delays and confusion.
• Notify of Critical Changes
  • Recommendation: Inform the team promptly about unexpected changes in patient status or vital signs.
  • Example: The nurse notifies the physician about a patient's renewed tachycardia, prompting further action.
  • Why: Critical changes can be missed in the EHR, so timely verbal communication ensures appropriate follow-up.
• Don’t Rely Solely on Electronic Orders
  • Recommendation: Always confirm important orders verbally to ensure timely action.
  • Example: The physician informs the nurse about the antibiotic order to meet sepsis treatment timelines.
  • Why: Nurses may not immediately see electronic orders, so verbal communication ensures prompt action.
• Use Asynchronous Communication for Lower-Priority Items
  • Recommendation: For non-urgent matters, use asynchronous communication to reduce interruptions.
  • Example: A nurse leaves a note requesting electrolyte orders for a patient with mild lab abnormalities.
  • Why: This reduces disruptions while helping prioritize urgent tasks.
•  Adapt Communication to Experience Levels
  • Recommendation: Tailor communication based on team members’ experience and relationships.
  • Example: A shift huddle introduces team members, allowing them to understand each other’s experience levels.
  • Why: Understanding the experience level of team members reduces misunderstandings and improves collaboration.
• Adapt Communication to ED Layout
  • Recommendation: Modify communication strategies based on the ED’s physical setup and visibility of team members.
  • Example: Regular rounds between physicians and nurses to discuss shared patients and potential issues.
  • Why: Reduced physical proximity can hinder awareness, so rounding helps address concerns promptly.
•  Leverage Provider Experience, Regardless of Hierarchy
  • Recommendation: Consider insights from experienced staff members, regardless of role.
  • Example: An experienced charge nurse advises a resident to upgrade a patient’s care based on clinical judgment.
  • Why: Experience-based recommendations from all team members can improve patient care and team efficiency.

Source

Sexton JB, Adair KC, Pina M, et al. Ten best practices for improving emergency medicine provider–nurse communication. J Emerg Med. 2020;58(6):865-870. doi:10.1016/j.jemermed.2019.10.035 

Patient Handover

Accurately conveying key information to a transition team during care handoffs is critical for maintaining patient safety and ensuring continuity of care.

Effective Handover Strategies

1. Standardized Protocols and Checklists: Use structured tools like the I-PASS handoff framework, which includes elements such as Illness severity, Patient summary, Action list, Situational awareness, and Synthesis by receiver. These tools help ensure completeness and clarity while minimizing information loss.

2. Face-to-Face and Two-Way Communication: Direct interactions allow for clarification and immediate questions, reducing miscommunication. Employing closed-loop communication—where the receiver repeats key information to confirm understanding—further enhances accuracy.

3. Limiting Interruptions: Create an environment free from distractions to allow for focused information exchange. This can include timing handoffs outside of high-traffic or peak activity periods.

4. Comprehensive Information Sharing: Include critical details such as patient condition, treatment plans, potential complications, and post-operative care needs. This also involves integrating relevant documentation, like lab results or imaging data.

5. Team Member Preparation: Both giving and receiving teams should review pertinent patient data beforehand. This readiness supports efficient and thorough handoffs.

6. Training and Simulation: Regular training and the use of simulation exercises can help teams practice and refine handoff processes, aligning with best practices from other high-risk industries like aviation and nuclear power.

Sources

Barbeito, A., Agarwala, A. V., & Lorinc, A. (2018). Handovers in perioperative care. Anesthesiology Clinics, 36(1), 87-98. https://doi.org/10.1016/j.anclin.2017.11.005

Lane-Fall, M., Pascual, J., Peifer, H., Di Taranti, L., Collard, M., Jablonski, J., Gutsche, J., Halpern, S., Barg, F., & Fleisher, L. (2020). A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units. Annals of Surgery, 271(3), 484-493. https://doi.org/10.1097/SLA.0000000000003569