Synthesis and Diagnostic Decision Making in an ED

Physicians and nurses who excel at solvingdiagnostic problems via teamwork are drawn toEmergency Medicine where individuals workingwith limited information must rely on each other todivine the best strategy for each patient. Of course,these skills usually are practiced in an environmentof steady distraction and disrupted communication.This is a chronic problem for the individualsputting the puzzle pieces together in a frenziedenvironment.

Getting the diagnosis right with minimal delaydepends on effective team communication. If Dr.B doesn’t know what Nurse A knows, then Dr. Bcan’t complete the picture of patient C.Every ED presents at least some of these significantchallenges to ensuring that the entire care team hascommon knowledge:

• an EMR that reduces face-to-face interactions among the ED staff
• a lack of touch-points for providers to synthesize independent bits of knowledge about a patient, especially at changes of shift
• staff that over rely on each other’s habits and tendencies as substitution for asking and confirming
• a lack of sharing subtle changes in a patient’s condition that are noticed, but not noteworthy

Peer-to-peer interactions, clinician-patientdiscussions, medical record documentation, etc., haveto be clear enough to assist contemporary providersand comprehensive enough to guide subsequentcaregivers. Organizations that offer training, practice,and support for teamwork skills that enhanceclinical decision-making can minimize the riskof uncoordinated care. Continuous collaborationbetween physician and nurse leadership that involvesfront-line workers from all disciplines is likely to beeffective in driving sustained safety improvements.

How well are you communicating critical information regarding your patient’s condition?

CASE EXAMPLE: DECISION-MAKING

A 47-year-old male with history of asthma presented to the EDcomplaining of shortness of breath and chest tightness since theprior day. The initial nursing documentation reports SOB episodesconsistent with asthma symptoms and a pulling pain in the chestwith deep breaths. They also referenced a recent history of apulled calf muscle one week prior, with bruising and swelling, anda positive Homan’s sign. The attending physician noted the patientwas alert, fully oriented, and in no acute distress. The patient alsoreported recent exposure to new cleaning products at work.

Without scrolling further down in the electronic medical recordto view the nurse’s note, the physician ordered no further studies,diagnosed the patient with asthma exacerbation, and dischargedhim with instructions to use his inhaler at home. The following day,the patient was found dead at home, secondary to massive bilateralpulmonary embolism. (Case settled: $315K).