Effective Communication
Effective communication is essential in successfully assessing and resuscitating critically ill trauma patients, especially in times of high stress. It is important to maintain a common vocabulary, creating a shared mental model of the case to avoid assumptions.
What is a shared mental model?
Creating a shared model of the patient’s situation allows personnel from differing backgrounds to understand both the clinical and logistical implications of the case. It ensures that team members are familiar with one another’s roles and responsibilities; that they are able to anticipate the needs of other team members, and have a high level of adaptive capacity9. This collaborative approach helps break down boundaries between individuals with varying levels of experience. It also helps reduce the perception of a power differential between outside specialists coming into the emergency department. Stating common treatment goals prevents individual team members veering off on counterproductive tangents. An example of this is an orthopaedic surgeon fixating on a dislocated ankle while the patient has a life-threatening pneumothorax that needs dealing with first. A way of doing this is to brief the team prior to the patient’s arrival.
Briefing the team
Even before the trauma patient arrives in the department the team leader should gather the team and brief them. The aim of the briefing is to:- allocate individual roles (for example, airway doctor/nurse)
- allocate tasks to be completed before the patient arrives (for example, draw up drugs, prepare for a chest drain insertion, pre-notification of radiology/blood bank/theatre)
- create a shared mental model of the patient’s current status as well as the anticipated plan and final destination
- create awareness of potential issues and how they might be dealt with (anticipate the ‘what if?’ scenario)
- allow the team to ask questions and clarify any issues before the patient arrives.
Tacit vs explicit communication
Tacit knowledge can be described as that which is acquired through practice and experience and may be difficult to communicate10. The same idea can be applied when referring to communication skills in the ED. Tacit communication is communication that occurs, often without words, in which the intention is never actually stated. One example of this is an experienced anaesthetist putting their hand out and expecting to be handed the laryngoscope by their assistant without actually asking for it because that is the way they do things. It should be obvious that this method can lead to problems, especially in occasional teams in times of high stress.
By making communication explicit and specific such as ‘When I do … I would like you to do …’ and allowing questions to be asked, errors and critical incidences can be avoided. In times of high stress communication often shifts from an explicit to a tacit form without the team being aware of it. This leads to missed information and poor outcomes.
One technique that can help avoid this is using closed-loop communication.
Closed-loop communication
Once the team leader has either requested information or asked for a procedure to be performed by a named person, they should then acknowledge the request explicitly and then state when it is done. This allows for clarification of requests if needed and avoids errors of omission. Closed-loop communication allows the sender to know that their requests have been heard and understood.Example: ‘James, I want you to insert a large-bore IV, please.’
'You want me to insert a 16-gauge IV?’
'Correct.’
Closed loop communication has been shown to reduce error rates by removing ambiguity from instructions, allowing questions if the instruction was not heard clearly, and it allows others in close proximity to be aware of the proposed course of action. 7
It is also especially important when ordering drug doses, especially if they are unfamiliar. If one asks for '50 of propofol’', do you mean 50 mg or 50 mL? It would be better to state, ‘I’d like you to give 50 mg, that is 5 mL of propofol.’
The use of names avoids the problem of such requests being made to an empty space. When a team leader asks out loud for an IV to be inserted, unless s/he specifies who s/he wants to perform the procedure then there is a risk it will not be done at all.
It is important that the team leader also uses eye contact when making requests, allowing for non-verbal as well as verbal clarification. The leader doesn’t bark orders but should be concise and clear in their language in order to get the task done.
Handover
ISBAR is an acronym for facilitating health professional communication ensuring clarity and completeness of information in verbal communication. By using a structured approach one can avoid missing vital information. By consistently using the ISBAR format for handover the team can anticipate what is coming next and be aware when important information is being presented:Identify: Who are you and what is your role? Patient identifiers (at least three).
Situation: What is going on with the patient?
Background: What is the clinical background/context?
Assessment: What do you think the problem is?
Recommendation: What would you recommend? Identify risks – patient and occupational health and safety. Assign and accept responsibility accountability.11
Situation: What is going on with the patient?
Background: What is the clinical background/context?
Assessment: What do you think the problem is?
Recommendation: What would you recommend? Identify risks – patient and occupational health and safety. Assign and accept responsibility accountability.11
Remote support and communication
The formation of a trauma or deteriorating patient response team may be very different among health services with highly variable capacity. Developments in both technological hardware and communication infrastructure have allowed healthcare services to extend their information base beyond in-house capacity, through using videoconference (VC) technologies. Difficult major trauma patient presentations, particularly when there is no or only off-site medical cover, require additional support to optimise patient care. The connection to a ‘remote expert’ to assist in identifying differential diagnoses and to guide ongoing assessment and intervention can be facilitated by Adult Retrieval Victoria (ARV) consultants. Where structures do not exist to allow VC consultation, voice-only teleconferencing with ARV allows for ongoing dialogue regarding best management of the major trauma patient.
Current structures allow for many Victorian health services to connect with critical care coordinators at ARV to provide expert guidance in managing major trauma patients. Engaging a VC support person has been shown to improve the confidence and abilities of attendant staff in managing acutely unwell patients. Systems currently in place allow for high-quality video and voice transmission to add value to the on-site clinical assessment of major trauma patients. The capacity of VC support lends itself to wide-ranging consultation, including reviewing x-rays and electrocardiographs in addition to major trauma patient assessment and interventional support.
Interactions over VC and teleconference technologies may require a change in approach, with some additional training and exposure, and the dissolution of barriers to involving an additional and external expert. However, identified positive outcomes necessitate health services embracing the use of VC and teleconference technologies to build staff confidence and skills and therefore improved patient outcomes.