To the Editor: I would like to compliment Coiera et al for their very interesting article about communication in an emergency department.1 Nearly a third of communication events were classified as interruptions, thus having an adverse effect on communication within the department.

In trying to reduce this level of interruption, perhaps it is time to rethink the role of the on-call emergency physician in an emergency department. In most large Australian emergency departments, the emergency physician is also the admitting officer, who is responsible for coordinating the non-elective admissions of the day. This involves being readily available for external and internal phone calls, usually by mobile phone. Thus, as well as the normal clinical workload of an emergency physician, he or she needs to respond immediately to the summons of a mobile phone — a recipe for interruptions and less efficient communication.

It is not optimal for the person who has clinical responsibility for the emergency department to also be the person through whom most of the communication is channelled. One possible solution is to channel calls about patients whom the referring doctor considers definitely need assessment in the emergency department to non-medical clerical staff. They could enter the details in a computerised "expected patients" database, which would be available for viewing by emergency department staff. Only calls about patients where there is some uncertainty, and advice calls, would be channelled to the emergency physician on call. This would facilitate both planning of the emergency department workload and also provide access to advice for the referring doctor. This change in process would reduce the number of phone calls received by the on-call emergency physician — and thus the number of interruptions — and improve overall communication within the emergency department.

To the Editor: Coiera et al1 should be congratulated for highlighting the excessive communication workloads of emergency department clinical staff, and the potential for these to be a source of errors and adverse events. However, their article fails to discuss the confounding variables, making it difficult to assess the validity of the communication strategies the authors propose to remedy the problem, or the applicability of their findings to other institutions.

Emergency department overcrowding results from lack of access to hospital beds.2,3 Situations in which the number of patients exceeds the number of available beds (as depicted in the emergency department shown on the cover of the same issue of the Journal) are of particular concern, and would be expected to be a significant factor in the communication workload of clinical staff.

Furthermore, many emergency departments do not have ward clerks, which means emergency department clinical staff perform the functions delegated to ward clerks in other hospital areas. The lack of direct telephone access to patients in the emergency department means that telephone calls from family members to a patient have to be directed through clinical staff. This increases the exchange of information between clinical staff, especially when the emergency department is overcrowded and patients are moved within the department to accommodate new patients. It is not clear, from the communication workload identified in Box 3,1 whether these factors were relevant in the institutions surveyed.

In addition, Coiera et al do not indicate the seniority of the six doctors they studied. This is important given that the ratio of staff specialists to registrars or junior staff in emergency departments may be two to three times that of inpatient wards, increasing the number of times staff specialists communicate to junior medical staff in the emergency department. Finally, there is no mention of the adequacy of nursing staff numbers during the survey periods. If there were a lack of nurses, or if there were nurses on duty who normally do not work in the emergency department, one would expect an increase in communication between nurses.

When emergency department infrastructure is so stressed, important studies, like that of Coiera et al, need to describe their findings in context, because of the likelihood of communication problems emerging as a result of health system failures.

To the Editor: I was interested in the report by Coiera et al1 about communication in the emergency department and the accompanying editorial by Vincent and Wears2 (from the United Kingdom and the United States, respectively, where, incidentally, the practice of emergency medicine differs significantly from that in Australia). In no other discipline is facility in communication between doctors, nurses, patients and relatives, as well as colleagues in other departments, of greater importance, given the paucity of information at presentation and the time constraints for assessment, management and appropriate referral — all within a time frame of a few minutes to several hours, depending on the severity of the presenting complaint. Vincent and Wears allude to the "fluidity and complexity of the clinical environment" and rightly suggest that studies need to be designed to embrace a "need to appreciate clinicians' decision making and cognitive load".

It was therefore disappointing that, after so much effort, Coiera et al did not correlate their data with severity of clinical condition and/or outcome (eg, requiring resuscitation, assessment for possible admission, treatment solely in the emergency department, or discharge to outpatients clinic or home, to name but a few possible groupings). These may, of course, be intended for future publication.

Regrettably, it is not stated how much input, if any, in the design and conduct of the study was obtained from staff in the unidentified emergency departments, and their contribution goes largely unacknowledged. As Richardson3 has pointed out, the active participation of at least one member of the emergency medicine staff (preferably senior and experienced) in such studies enhances motivation in staff busy with other priorities, and facilitates cooperation and collaboration (which can thereafter properly be recognised in co-authorship).

There is also a danger that in the current litigious climate an inadvertent emphasis on "errors and poor outcomes" may prejudice the real benefits of the worthwhile objective of assessing the nature, relevance and value of improved communication between those engaged in clinical practice. Nonetheless, it is encouraging to deduce from this report that, in emergency departments, doctors and nurses regularly speak to each other, presumably with an optimal outcome for the patient in mind.

For one who spent two decades as head of a busy, metropolitan emergency department, it is reassuring to find, in a discussion of informatics, advocacy2 for a return to the "white board", which, even today, remains the mainstay of patient information and tracking in many emergency departments.

In reply: We know little about communication systems in healthcare, and our study is still only one of a handful that quantify communication processes. Consequently, the aim of our pilot study, as well as reporting specific emergency department communication patterns, was to develop a robust general observational methodology, and measures of communication load.1

With the evidence that communication load is an issue, the next stage in the research would be to design studies to identify variables that could, in principle, affect communication load, as suggested by both Nocera and Hamilton. Indeed, there are many such variables — staff level and experience, organisational structure, clinical task, patient acuity, communication infrastructure, departmental policy, etc. The difficulty we will face is to control for many of these variables, and this will require longitudinal studies and samples from multiple sites.

Hence, we are not yet able to make specific recommendations about interventions to "improve" communication in emergency departments. Indeed, there are no benchmarks against which to compare these data, so we cannot even say whether the data reflect good practice.

Given these uncertainties, we agree with Nocera that it is too early to say which interventions would be appropriate to the specific circumstances of emergency departments, and we made no specific recommendations ourselves, but rather summarised commonly suggested interventions. Nocera and O'Connor also suggest other interventions which in their clinical experience may improve communication loads in emergency departments. It is likely that the variability of organisational settings will mean most such interventions will need to be customised to local conditions and needs.

Hamilton is correct to highlight the tension in reporting data on organisational performance, and the risks of these data being misinterpreted or misused. Given these risks and the lack of comparative benchmarks, we explicitly chose not to comment on performance, nor to identify the organisations or participating clinicians. However, we would not have been able to carry out the study without the full cooperation of the staff at both hospitals, and, while they remain anonymous, we are deeply indebted to them for their willingness to welcome us into their workplace, volunteering to be subjects, and allowing us to observe them as they carried out their work.