Take a deep breath . . . and talk

Eighty fewer deaths were recorded in the year following the adoption of the 4-hour rule by the emergency departments (EDs) of three tertiary hospitals in Western Australia1 — equivalent to almost half the state road toll. This remarkable result is regarded by some as preliminary. But if it stands the test of time, it will be testament to what is achievable with good up-front resourcing from a health department, plus improved communication — in this case, between the ED and the wards.

Improving communication between two other “factions” in emergency care would make it easier to meet the 4-hour target, now the “National Emergency Access Target”. It would also improve patients’ experiences in the ED, help allocate resources more efficiently, and hopefully reduce the unconscionable, rampant abuse directed by patients at medical staff.2

The two factions that I refer to are the ED staff and their patients. This year, I witnessed just how poor communication between them can be when I visited the ED of a busy children’s hospital four times, with two different children, at various times of day and night.

This particular ED was a veritable communications black hole: in went referral letters, symptoms, samples; indeed, two children to be examined, measured, weighed and monitored. And out came, well, nothing at all.

Could they give me any idea of the waiting time? No. Whether my child’s condition was deemed an emergency? No. What would happen next? No.

Such experiences are common, according to Professor Diana Slade, an applied linguist at the University of Technology, Sydney. Slade and her colleagues spent 3 years observing 1093 hours of communication between patients and clinical staff, and interviewing 150 staff and patients, in five representative EDs.3

Nor is it just patients who have trouble getting information from EDs: general practitioner Steve Trumble couldn’t even get the Admitting Officer at one ED to give his name.4

That poor communication in hospitals causes serious harm, even death, is incontrovertible.5 It reduces patients’ ability to be partners in their own care, costs money, and is a major cause of complaints.

In my case, being kept in the dark contributed to one child being “lost to the system”, occupying a bed for much longer than necessary as we waited for an ultrasound that no one had ordered, but everyone thought had been ordered. Had I known to expect an hour’s wait, I would have alerted someone to the oversight.

It also meant that I had only my gut instincts to guide my decision about remaining in the ED with one child, or leaving to attend to the competing needs of the other, which, not incidentally, would have freed up resources for someone in greater need.

EDs are fast-paced, high-stakes places where needs and resources change from one minute to the next. Staff multitask and handball so much critical information that there is a real risk of communication overload leading to clinical error. Patients usually have no idea what happens behind those sliding doors — what “triage” and “emergency” really mean. They may be juggling multiple responsibilities of their own.

And that is the nub of the problem — the different and competing needs for information and outcomes. “The hospital has one agenda — to get people through in 4 hours. Clinicians want to reach the correct diagnosis as quickly as possible, while the evidence tells us that first and foremost patients want their anxiety dealt with, to feel that they are being treated by an expert”, says Slade.

One obvious solution is to better align those competing agendas. “I don’t doubt for a moment the extraordinary dedication of these doctors”, Slade says. “But the quickest way to get a diagnosis is to develop rapport and empathy with your patients.” The quickest way to get a patient through the ED may be to tell them accurately yet sensitively that their condition, or that of their child, is a low priority and they will have a long wait.

The Slade team’s seven evidence-based recommendations included training clinicians in communicating across disciplines, cultures and hierarchical levels in the ED setting, and explicitly telling patients their triage category and the expected wait time. “People are usually decent. They understand that [their position] can change if three people come in in cardiac arrest. But they need information so that they can work out whether to stay or seek alternative care.”

Health departments and hospitals should jump at the opportunity to translate this communications research into more humane, timely and efficient emergency care.