Physicians and nurses who excel at solving
diagnostic problems via teamwork are drawn to
Emergency Medicine where individuals working
with limited information must rely on each other to
divine the best strategy for each patient. Of course,
these skills usually are practiced in an environment
of steady distraction and disrupted communication.
This is a chronic problem for the individuals
putting the puzzle pieces together in a frenzied
environment.
Getting the diagnosis right with minimal delay
depends on effective team communication. If Dr.
B doesn’t know what Nurse A knows, then Dr. B
can’t complete the picture of patient C.
Every ED presents at least some of these significant
challenges to ensuring that the entire care team has
common 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-patient
discussions, medical record documentation, etc., have
to be clear enough to assist contemporary providers
and comprehensive enough to guide subsequent
caregivers. Organizations that offer training, practice,
and support for teamwork skills that enhance
clinical decision-making can minimize the risk
of uncoordinated care. Continuous collaboration
between physician and nurse leadership that involves
front-line workers from all disciplines is likely to be
effective 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 ED
complaining of shortness of breath and chest tightness since the
prior day. The initial nursing documentation reports SOB episodes
consistent with asthma symptoms and a pulling pain in the chest
with deep breaths. They also referenced a recent history of a
pulled calf muscle one week prior, with bruising and swelling, and
a positive Homan’s sign. The attending physician noted the patient
was alert, fully oriented, and in no acute distress. The patient also
reported recent exposure to new cleaning products at work.
Without scrolling further down in the electronic medical record
to view the nurse’s note, the physician ordered no further studies,
diagnosed the patient with asthma exacerbation, and discharged
him with instructions to use his inhaler at home. The following day,
the patient was found dead at home, secondary to massive bilateral
pulmonary embolism. (Case settled: $315K).