Emergency Department Triage (2024)

December 1, 2024December 1, 2024 ~ iEM Education Project Team ~ Leave a comment

by Priya Arumuganathan and Scott Findley

Introduction

Triage is the process of sorting patients by severity of illness to ensure care is administered in a timely fashion according to each patient’s need. When specifically applied to the emergency department, “Emergency Department (ED) Triage” is used to quickly assess, risk-stratify, and manage incoming patients before their complete evaluation. A triage process allows systems to safely operate an influx of multiple patients with varying acuity levels in situations when clinical demand exceeds capacity. Formal triage systems have been employed since as early as the 19th century in warfare settings to effectively handle the growing amounts of field casualties [1].

Today, emergency triage can be generally separated into three distinct phases: prehospital triage, triage at the scene, and emergency department triage. Many different types of triage systems have been developed and implemented worldwide [2]. In this section, we will focus on emergency department triage and some of the most well-known triage systems globally.

Performing a Rapid Triage Assessment

The “rapid triage assessment” is essential to any triage system. Those performing the rapid triage assessment should have some clinical experience and a keen eye to quickly identify patients who need to be seen urgently. The goal of triage is to determine which patients need immediate attention, which patients can wait to be seen, and to manage large patient volumes safely. To accomplish this, one must gather pertinent history and physical exam findings quickly and efficiently.

Performing a Focused History

Obtaining a quick and focused history is of utmost importance during the rapid triage assessment. To summarize, providers must be able to get symptoms pertinent to the patient’s presentation, any relevant events leading to their presentation, and pertinent past medical history and allergies. One mnemonic that is useful and used by many for history-gathering is SAMPLE (as below) [3]:

The SAMPLE mnemonic is a structured method for gathering key clinical information during an emergency assessment. It serves as a framework for emergency medical personnel to obtain essential details quickly and efficiently, allowing them to prioritize care and decide on the best course of action. Each component of the mnemonic corresponds to a specific area of focus in history-gathering, which is vital for rapid triage in the emergency department or pre-hospital setting. Below is a more detailed breakdown of each element:

S – Signs & Symptoms
The first and most immediate part of the assessment focuses on the patient’s presenting signs and symptoms. These may include both subjective (what the patient describes) and objective (what the healthcare provider observes) data. For example, a patient may report chest pain, difficulty breathing, or nausea, while a provider might note abnormal vital signs or physical findings. It’s crucial to obtain a clear description of the symptoms, including onset, duration, intensity, and any factors that may have worsened or alleviated them. Understanding the signs and symptoms will help determine the severity of the condition and direct the urgency of intervention.

A – Allergies
Gathering information about any known allergies is vital in guiding treatment decisions, especially in emergencies where medications or interventions are required quickly. For example, if a patient has a known allergy to penicillin, it is essential to avoid using antibiotics in that class. Allergies to food, medications, environmental triggers, and latex should all be considered. In addition, healthcare providers should be mindful of potential allergic reactions that could complicate the management of the patient’s condition.

M – Medications
A comprehensive medication history helps identify substances that may impact the patient’s current clinical situation. This includes prescribed medications, over-the-counter drugs, supplements, and any recent changes to a medication regimen. For example, a patient taking blood thinners such as warfarin may require careful monitoring for signs of bleeding, while those on insulin may need their blood sugar levels closely monitored. Knowledge of recent changes, doses, and the possibility of drug interactions is crucial in the emergency setting.

P – Past Pertinent History
Past medical history (PMH) can provide essential context for understanding the patient’s current presentation. This includes chronic conditions such as diabetes, hypertension, or asthma, as well as previous hospitalizations, surgeries, or significant illnesses. Understanding a patient’s medical history helps healthcare providers anticipate complications and tailor their approach. For instance, if a patient with a history of seizures presents with altered mental status, healthcare providers will prioritize ruling out or treating seizure activity or postictal states.

L – Last Oral Intake
Knowing the last oral intake—what the patient has eaten or drunk—can provide valuable information about the patient’s condition, especially in cases of poisoning, drug overdoses, or gastrointestinal distress. For example, the timing of food or drink ingestion could suggest an issue with digestion or absorption, which may influence the choice of interventions. In cases of poisoning, knowing whether the patient ingested a toxic substance recently can impact the decision to administer activated charcoal or other antidotes. Additionally, the last oral intake can be crucial if the patient is scheduled for surgery or other procedures, as it helps assess the risk of aspiration or anesthesia complications.

E – Events Leading to the Incident
Understanding the sequence of events that led to the current emergency is essential for diagnosing the cause and assessing the patient’s clinical needs. For example, was the patient involved in a motor vehicle accident, or did they experience a sudden onset of chest pain while exercising? Gathering this information helps to identify the mechanism of injury or the type of acute event, which could significantly alter the emergency management plan. It also provides insight into potential causes of the symptoms and any necessary preventive or therapeutic actions.

Purpose and Application of the SAMPLE Mnemonic in Rapid Triage

The SAMPLE mnemonic is a concise tool designed to quickly gather relevant historical information that can significantly impact clinical decision-making in the emergency department. This structured approach is particularly helpful in high-pressure environments where time is critical, such as during triage or when managing patients with complex or time-sensitive conditions.

The goal during history-gathering in an emergency is to obtain just enough, but not too much detail. Too much detail may delay treatment, while too little may result in missing critical information. For example, a lengthy review of a patient’s family history may be less pertinent in an acute situation compared to knowing their current medication list or the events leading to the emergency. The SAMPLE framework ensures that the provider gathers relevant information to make informed decisions about the next steps in care, whether that be immediate intervention, further diagnostics, or a more detailed secondary assessment.

The SAMPLE mnemonic is an effective tool for emergency practitioners to rapidly gather crucial information during triage and initial assessment. By focusing on the most important elements—signs and symptoms, allergies, medications, past medical history, last oral intake, and events leading up to the incident—providers can prioritize interventions, anticipate potential complications, and provide optimal care in emergency settings.

Performing a Focused Physical Exam

After performing a focused history, it is important to use the information gathered to guide your focused physical exam. For example, a patient presenting with the chief complaint of sore throat should receive an expedited examination of the head, ears, mouth, and neck. The rest of the physical exam should be deferred unless the patient has another complaint that is not covered by these sections. The purpose of the focused physical exam is to look for “red flag” exam findings that would warrant more immediate attention and intervention, such as the peritonitic abdomen in the patient presenting with abdominal pain, oropharyngeal swelling in the patient presenting with shortness of breath and rash, left-sided flaccidity in the patient presenting with sudden onset weakness and tingling, and other concerning findings [4].

Vital Signs and Objective Data

There are clues to key providers about how sick their patients are. One of the most important clues is a patient’s set of vitals; therefore, it is exceedingly important to obtain a full set of vitals for all patients arriving at the emergency department. Vitals at either extreme of the spectrum are equally important, and grossly abnormal vitals should prompt a more expedited triage and shorter waiting times. Other clues that help identify sick patients include the level of pain, duration of symptoms, level of consciousness, and mechanism of injury. Suppose someone is determined to be in distress at any point during the triage process. In that case, they must be brought to a designated patient care area for immediate ED provider attention. In the paragraphs below, we will discuss this further regarding adult populations.

Heart Rate

Bradycardia is a heart rate of less than 60 bpm, while tachycardia is a heart rate of more than 100 bpm [5]. If a patient is experiencing associated hypotension with an abnormal heart rate, then it is obvious that they are sick. However, there are other key questions that you may ask in the physical exam to elucidate further a patient’s severity of illness regarding an abnormal heart rate. For example, experiencing associated chest pain, palpitations, extreme fatigue or weakness, altered mental status, shortness of breath, or nausea can be signs that the abnormal heart rate is due to a concerning underlying pathology in the patient. Tachycardia can be indicative of infection, dysrhythmia, acute blood loss, and toxin exposure amongst other etiologies. It is also important to ask about medication use in these patients as this can be your first sign of an accidental (or intentional) chronotropic medication overdose – such as with beta-blockers, calcium channel blockers, and other medications that need to be seen by a medical provider quickly.

Blood Pressure

Hypotension is defined as a blood pressure less than 90/60 mmHg, while hypertension is defined as more than 140/90 mmHg [5]. With hypotension, it is important to first quickly assess if a patient is experiencing a decreased mental status and level of alertness in order to determine if any immediate interventions are needed – if so, this patient is definitely sick and cannot wait for care. Next, it is important to assess for possible causes of hypotension and severe illness, such as septic, hemorrhagic, neurogenic, and anaphylactic shock. For hypertension, it is important to assess for signs that could indicate end-organ failure, such as chest pain, shortness of breath, and focal neurologic deficits. Patients exhibiting the above symptoms should be evaluated sooner rather than later.

Respiratory Rate

Tachypnea is defined as a respiratory rate above 20 bpm, while bradypnea is defined as a respiratory rate below 12 bpm [5]. Apnea is the total absence of breathing. Bradypnea and apnea can be seen in many conditions, including traumatic brain injury and heroin overdose. Tachypnea is seen in many conditions, including asthma exacerbation and conditions causing metabolic derangement, such as diabetic ketoacidosis. If a patient is not breathing or experiencing decreased oxygen saturation along with abnormal respirations, then it is obvious they are sick. However, for those cases that are less obvious, it is important to observe the patient’s work of breathing with their respirations. Those who appear to have a significantly increased respiratory effort, are becoming tired, or are experiencing shallow respirations will need medical evaluation and care sooner rather than later. Their fatiguing respiratory effort will eventually lead to respiratory failure and hypoxia. Those with stories concerning an underlying process that could quickly compromise respiratory function should also be prioritized. For example, a patient who presents with a story suspicious of intracranial hemorrhage who appears sleepy and only moans in response to questions is at high risk for respiratory decompensation.

Oxygen Saturation

Hypoxia is defined as an oxygen saturation below 92% [5]. While different patients can tolerate various oxygen saturation levels depending on their smoking status, history of lung disease, and other past medical history, it is important to assess the work of breathing and level of alertness in patients with low readings. Patients who appear to have increased work of breathing, decreased respirations, or decreased level of alertness are at risk for respiratory decompensation. These patients should be evaluated and treated sooner rather than later.

Temperature

Hypothermia is defined as a temperature below 35 C. In contrast, hyperthermia is defined as a temperature above 38 C [5]. Hypothermic patients must be rewarmed depending on the degree of hypothermia (this will be discussed in later chapters). It is important to determine the reason for their hypothermia – such as sepsis, submersion injury, and prolonged cold exposure. There are many reasons for hyperthermia, including but not limited to infection, prolonged heat exposure, and certain types of medication overdose. The hyperthermic patient must be physically cooled and given antipyretics or other medications depending on the cause of their hyperthermia. These are all causes for concern and immediate interventions.

Pain

The severity and location of pain can also help identify patients who need prompt attention. Patients in severe pain will need immediate attention and medications to alleviate their pain. The location of pain can also be a clue to a patient’s severity of illness. For example, chest pain radiating to the back could represent an aortic dissection, right lower quadrant abdominal pain could represent appendicitis, and headache with neck stiffness could represent bacterial meningitis. Patients with concerning pain severity and location should be prioritized [6].

Duration and Mechanism

The duration of symptoms can also be a clue to a patient’s severity of illness. In general, acute complaints, or complaints that occur with a sudden or recent onset, should raise higher suspicion for serious etiologies than a chronic complaint that has been occurring without change for weeks to months [6]. A patient’s mechanism of injury is also important to consider; for example, a person who has fallen from a significant height or has been involved in a high-speed accident should be evaluated quickly as well.

Level of Consciousness

Level of consciousness exists on a spectrum, from those who are unresponsive to those who are completely awake and alert. Unresponsive patients should receive immediate attention and interventions, including chest compressions if they are without a pulse and intubation. Lethargic patients and those experiencing quickly decreasing levels of alertness should also be prioritized. Those sleepy or confused should be seen urgently, while those fully awake and alert may wait to be seen if they are without other concerning signs/symptoms [6].

Triage is a complex process involving several components, and it can be challenging. Triage providers play a crucial role in ensuring the efficiency and safety of the ED. They must quickly and accurately assess a patient’s severity of illness to determine how long different patients can safely wait for care. It is essential that they do not focus on diagnosing the patient’s condition during triage, as this can delay the process. Such delays can compromise care for all patients, allowing seriously ill individuals to go unnoticed for extended periods while their condition worsens. Remember that a comprehensive history, examination, diagnostic work-up, and treatment will occur once the patient is admitted to a care area.

Triage Systems

Triage is a complex process that needs to be done expediently, especially when facing large patient volumes. Fortunately, many triage systems have been developed to help guide providers in quickly and accurately risk-stratifying patients during the rapid triage assessment. We will discuss some of the most popular and widely used triage systems, such as the Manchester Triage System and the Emergency Severity Index.

Manchester Triage System

One of the most well-known and globally used triage systems is the Manchester Triage System (MTS). It was developed in the UK and is widely used worldwide. This triage system helps ensure patient safety by defining the maximum time each patient can wait before being seen and treated. The MTS contains flowcharts for various presenting complaints that help to distinguish the severity of illness based on key “discriminators” (signs and symptoms) [7]. Each level of severity is assigned a different color. Red indicates immediate evaluation, while blue indicates non-urgent evaluation (can wait up to 240 minutes). Flowcharts are available for various chief complaints in adult and pediatric patients. The MTS (Figure) for the adult chief complaint of “chest pain” is discussed below [8].

RED: Immediate/Life-Threatening

The red category signifies the highest level of urgency, where the situation is life-threatening and requires immediate medical intervention. The maximum waiting time is 0 minutes, indicating that the patient must receive attention without delay. Correlating examples for chest pain in this category include airway compromise, inadequate breathing, or shock. These conditions are critical as they can lead to rapid deterioration or death if not addressed promptly. Immediate treatment might involve airway management, advanced resuscitation, or stabilization of vital signs.

ORANGE: Emergent/Could Become Life-Threatening

The orange category represents conditions that are not immediately life-threatening but could escalate to critical levels if left untreated. The maximum waiting time in this category is 10 minutes, emphasizing the need for swift medical evaluation and intervention. Examples of chest pain scenarios in this category include severe pain, cardiac pain, acute shortness of breath, or abnormal pulse. These symptoms often indicate serious underlying issues such as myocardial infarction, severe arrhythmias, or pulmonary embolism, all of which require urgent diagnostic and therapeutic measures to prevent deterioration.

YELLOW: Urgent/Not Life-Threatening

In the yellow category, conditions are urgent but not immediately life-threatening. The maximum waiting time is 60 minutes, providing a moderate window for assessment and treatment. Correlating examples for chest pain include pleuritic pain, persistent vomiting, history of cardiac disease, or moderate pain. These symptoms may point to less severe causes, such as musculoskeletal issues, gastroesophageal reflux, or pleurisy. However, the history of cardiac disease suggests a need for careful evaluation to rule out more serious conditions.

GREEN: Semi-Urgent/Not Life-Threatening

The green category involves semi-urgent conditions where the likelihood of life-threatening complications is low. Patients in this category can wait up to 120 minutes for treatment. Examples include vomiting, mild pain, or recent problems. Chest pain in this category is typically associated with benign causes, such as anxiety, mild gastrointestinal issues, or a musculoskeletal strain. While these cases are not critical, timely assessment ensures patient comfort and prevents unnecessary progression of symptoms.

BLUE: Non-Urgent/Needs Treatment When Time Permits

The blue category is for non-urgent conditions that require treatment only when time permits. The maximum waiting time is 240 minutes, as these cases are unlikely to escalate to a critical level. Examples include other complaints that may not even directly relate to chest pain or are minor in nature. These could involve mild discomfort or non-specific symptoms that do not pose any immediate threat to the patient’s health. Such cases can be safely managed without priority over more urgent categories.

Emergency Severity Index

Much like the Manchester Triage System, the Emergency Severity Index triage system (developed in the USA) is also globally known and used. It stratifies patients into five levels: level 1, the most urgent, and level 5, the least urgent. It also helps to determine what resources are necessary to move a patient toward disposition. It is based on four key decision points: does the patient require life-saving interventions (Step A), are they in a high-risk situation (Step B), how many resources do they need (Step C), and what are their vitals (Step D)? The ESI Triage Algorithm, types of resources, and level of urgency, along with examples, are discussed below [9].

Step-by-Step ESI Triage Algorithm

Step A: The first question asks whether the patient requires immediate, life-saving interventions. If the answer is “Yes,” the patient is classified as Level 1, indicating the highest level of urgency. If “No,” the triage proceeds to Step B.
Step B: This step evaluates whether the patient is in a high-risk situation, is lethargic, confused, or in severe pain. A “Yes” response classifies the patient as Level 2, while a “No” response advances the process to Step C.
Step C: At this stage, the need for medical resources is assessed. If the patient requires only one resource, they are categorized as Level 4. If multiple resources are needed, they may qualify for a higher urgency level, prompting a review in Step D.
Step D: This step determines whether the patient exhibits “danger zone” vital signs, such as abnormal heart rate, respiratory rate, or oxygen saturation. A “Yes” response results in a Level 2 classification, while “No” leads to a Level 3 classification.

Types of Resources Defined by ESI

Resources play a critical role in the ESI system, as they help determine patient levels during Step C. Common resource types include:

Diagnostic Tools: Labs, EKG/ECG, X-rays, CT scans, MRI, or ultrasounds.
Treatment: IV fluids, IV/IM/nebulized medications, and specialist consultations.
Procedures: Simple procedures, such as laceration repair or Foley catheter insertion, are counted as one resource. Complex procedures, including conscious sedation, fracture reduction, and intubation, may require additional considerations.

Points according to required resources;

1 point for Labs (e.g., blood tests), EKG/ECG or X-rays, or Advanced Imaging (e.g., CT, MRI, or ultrasound).
1 point for IV fluids.
1 point for IV, IM, or nebulized medications.
1 point for a Specialist consultation.
1 point for a Simple procedure, such as laceration repair or Foley catheter placement.
2 points for a Complex procedure, such as conscious sedation, fracture reduction, or intubation.

These resource definitions allow triage staff to assess patient needs objectively. A higher number of resources often correlates with a more urgent ESI level.

ESI Levels and Their Corresponding Urgency

The ESI system categorizes patients into five levels of urgency based on their condition and resource needs:

Level 1 (Immediate): Patients need immediate attention due to life-threatening conditions like cardiac arrest.
Level 2 (Emergent): These patients are at high risk of rapid deterioration, such as those experiencing an asthma attack.
Level 3 (Urgent, Multiple Resources): Patients with conditions requiring multiple resources, like abdominal pain, fall into this category.
Level 4 (Stable, One Resource): These patients need only one resource, such as laceration repair.
Level 5 (Stable, No Resources): Patients with stable conditions requiring no resources, such as a prescription refill, are classified here.

Advanced Triage

Once you are comfortable with the above basic triage concepts, you can familiarize yourself with advanced triage considerations, such as ordering an initial diagnostic work-up and treatments.

Ordering an Initial Diagnostic Work-Up and Other Orders

As soon as a patient is determined to be sick or unstable, your priority should be to place them in a patient care area as quickly as possible for medical attention. You can then place initial orders, which should be directed toward stabilizing them. Placing IVs early and facilitating early medication/fluid administration can be life-saving measures. Be sure to ask these patients (or their loved ones) early in their evaluation regarding their wishes for cardiopulmonary resuscitation (CPR) and intubation. Once a patient is stable, or if they’re already stable, you can use their pertinent history and physical exam findings to guide your initial diagnostic imaging and labs. Consider your most likely diagnoses and “can’t miss diagnoses” when placing these initial orders [10].

Author

Priya Arumuganathan

Priya Arumuganathan, MD is a third year Emergency Medicine resident at West Virginia University. After residency, she will be completing a Global Emergency Medicine Fellowship at the University of Pennsylvania. During residency, Priya served as a Chief Resident and was very active in teaching core EM content, ultrasound skills, and procedural basics to medical students and new residents. Her rural background and training at several critical access hospitals have helped her build a foundation for working in low-resource environments, and she has been able to translate these skills to her global work. Her academic interests include EM education & training in low-resource environments, telemedicine, and rural health.

Scott Walker Findley

Dr. Findley is an associate professor with the WVU Department of Emergency Medicine. He splits time between the larger WVU academic centers and outlying rural emergency departments, spending most of his clinical time in single coverage facilities. After recognizing the challenges inherent in rural emergency medicine (EM), he designed and developed the WVU Division of Rural EM. Dr. Findley secured a federal telemedicine grant to expand telemedicine services in WV critical access hospitals, an institutional HOPE grant to assess per-birth needs in rural emergency departments, assisted with a rural specific response to COVID – 19, secured a position as medical director and advisor for Adventure WV, successfully launched a multisite rural EM rotation for residents, facilitated rural rotations for medical students, and oversaw the integration of rural EM lectures and simulated cases into the resident curriculum. In addition to remaining academically connected, Dr. Findley works closely with the WVU Emergency Department Divisions of ultrasound, EMS and Education to bring resources into the community sites and rural areas. Dr. Findley also sits on the national American College of Emergency Physicians (ACEP) Rural Emergency Medicine’s Task Force. He has taken an active role in research with local and national presentations as well as publishing in academic journals. Although these opportunities have been rewarding, Dr. Findley believes nothing teaches you more, maintains drive and sharpens focus better than pulling shifts and seeing patients and he plans to continue working the majority of his clinical hours in smaller departments.

Listen to the chapter

References

Robertson-Steel I. Evolution of triage systems. Emerg Med J. 2006;23(2):154-155. doi:10.1136/emj.2005.030270
Yancey CC, O’Rourke MC. Emergency Department Triage. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 31, 2022.
West Virginia Office of Emergency Medical Services. (2016, January 1). Assessment Mnemonics. Appendix D. Retrieved April 23, 2023, from https://www.wvoems.org/files/protocols/appendix/appendix-d-assessment-mnemonics
Society for Academic Emergency Medicine. (2008). Performing a complaint-directed history and Physical Examination. Clerkship Directors in Emergency Medicine. Retrieved April 23, 2023, from https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m3-curriculum/group-focused-chief-complaint-history-physical-examination-and-differential-diagnosis/performing-a-complaint-directed-history-and-physical-examination
Balakumaran, J. (2020, June 30). Interpreting critical vital signs. Medical Concepts. Retrieved April 23, 2023, from https://canadiem.org/interpreting-critical-vital-signs/
Mackway-Jones, K., Marsden, J., & Windle, J. (2014). The Triage Method. In Emergency Triage (2nd ed., pp. 10–21). John Wiley & Sons.
Cicolo, E. A., Ayache Nishi, F., Ciqueto Peres, H. H., & Cruz, D. A. (2017). Effectiveness of the Manchester Triage System on time to treatment in the emergency department: a systematic review protocol. JBI database of systematic reviews and implementation reports, 15(4), 889–898. https://doi.org/10.11124/JBISRIR-2016-003119
Ganley, L., & Gloster, A. S. (2011). An overview of triage in the emergency department. Nursing standard (Royal College of Nursing (Great Britain) : 1987, 26(12), 49–58. https://doi.org/10.7748/ns2011.11.26.12.49.c8829
Gilboy N, Tanabe T, Travers D, Rosenau AM. (2011). Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition. AHRQ Publication No. 12-0014. Rockville, MD. Agency for Healthcare Research and Quality.
International Emergency Medicine Education Project. (2019, March 4). Core Senior EM Clerkship Topics. Emergency Medicine Clerkship – Approach to Chief Complaints. Retrieved April 23, 2023, from https://iem-student.org/em-clerkship-topics/

Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Disaster Medicine Triage (2024)

April 8, 2024December 3, 2024 ~ iEM Education Project Team ~ Leave a comment

by Parker Maddox, Hassan Khuram & Scott Goldstein

A Brief Introduction to Disaster Medicine

Disaster Medicine is a medical discipline that centers around events significant enough that, without external aid, emergency departments (ED) would not be able to adequately provide care to those affected [1]. For example, a multi-vehicle car accident may result in multiple casualties, but would not be considered a disaster if the responding medical infrastructure was able to handle the influx of patients. Many entities including the United Nations International Strategy for Disaster Reduction (UNISDR) and the World Health Organization (WHO) have amended their definitions of the term “disaster” to specify occurrences that exceed a community’s ability to cope with the effects of said disaster [2,3]. Incidents that have satisfied this requirement include natural disasters and more modern occurrences such as water contamination, human conflict, chemical spills, radiation, power outages resulting in infrastructure collapse, etc. [1]. The field of disaster medicine operates with the goal of aiding with these disaster-level events and all of the associated medical, logistical, and ethical issues that come along with them [4].

This is accomplished through a joint effort by many disciplines within healthcare including emergency medicine (EM), Emergency Medical Services, pediatrics, public health, social work, and many more [5]. However, emergency medicine providers’ experience in high acuity, large patient volume settings set them up to take a leadership role in disaster medicine. The emergency department is also typically the first point of contact between patients and health care providers in a disaster setting providing emergency medicine physicians an advantage in these responses [6]. In addition to their traditional responsibilities of stabilization and disposition of disaster patients, EM physicians are typically delegated the responsibilities of coordinating disaster response as chief medical officer, interfacing with government and community relief efforts, and directing disaster triage efforts [6].

Disaster Triage

When a disaster occurs, hospital systems experience what is known as a critical care surge. This is defined as “any increase in the number of critically ill or injured patients beyond the baseline rate a hospital or critical care unit usually experiences.” [7]. These surges are classified based on the size of the critical patient increase with disasters typically causing large surges or megasurges. Megasurges are caused by grand scale, unexpected disaster events (tsunamis, earthquakes, terrorist attacks, etc.) and can require greater than 200% of the resource capacity a hospital has to care for patients [7]. This dramatic scarcity of resources in the face of overwhelming casualties results in an inevitable need to ration resources.

According to the World Health Organization, “triage” is the rapid examination and sorting of patients into groups according to their medical needs and the availability of resources [8]. In this setting of mass casualties and resource scarcity, disaster triage protocols are governed by the utilitarian concept of doing the greatest good for the greatest number[9]. As opposed to routine triage seen in the ED, this requires a shift of focus from the outcomes of single patients to outcomes on a population level [7].

However, despite the common misconception, disaster triage is not simply making the decision of whether to treat a patient or not. Disaster triage is more complex with most decisions centering around what level of treatment a patient should receive [7]. Rarely is it decided or even proposed that a patient should receive no treatment at all [7]. The consensus within disaster medicine is that disaster triage should optimize patient care and resource allocation by considering the incremental improvement in survival that a treatment would provide a patient in their current condition[10]. In order to make these decisions, the foundation of disaster triage lies in the use of triage tools and protocols to systematically assess patient conditions and prognoses following these devastating events. With proper triage and resultant treatment, it has been shown that trauma patients can experience at least a 25% reduction in mortality [11]. In disaster settings where hundreds to thousands of lives hang in the balance, 25% is not an insignificant number.

Measures of Success: Undertriage and Overtriage

Prior to discussing the wide array of triage methods used in disasters, it is pertinent to describe the terms used describe and assess them. Triage efficacy is typically judged by its validity, or how accurate the acuity assigned during triage, by tool or clinical assessment, is to the actual acuity of the patient. In order to measure this validity, we rely on rates of undertriage and overtriage observed during real world scenarios (Table 1) [12].

Concept	Definition	Impact	Sensitivity & Specificity	Acceptable Rate
Undertriage	Patient condition is classified as a lower acuity than it actually is.	Patients are under prioritized, under treated, and providers may miss savable lives.	Low sensitivity	Low (<5-10% of patients)
Overtriage	Patient condition is classified as a higher acuity than it actually is.	Patients are overtreated leading to disorganization, misallocation of scarce resources, and wasting time that could be used to save other patients.	Low specificity	Variable depending on context (25-35% and others 50-60%)

Table 1: Definitions, major impacts, relationships to sensitivity and specificity, and acceptable rates of overtriage and undertriage [11, 12, 13, 15, 17].

Undertriage

Undertriage is when a patient’s condition or injury is under classified in terms of acuity, and the patient is under prioritized or under treated as a result. This results in situations where critically ill patients could have benefited from a justifiable use of resources to further evaluate and treat their injuries [13, 14]. An example of this could be a severely injured patient that was transferred to a non-trauma center, or a patient that could have survived with prioritized evacuation and admission to the ICU or OR. However, it is worth noting that moderately injured patients are the most often undertriaged since severe acuity patients are more easily recognized [11]. Nonetheless, these are essentially missed opportunities to save patients and, statistically, this would represent a low sensitivity of the triage process. Therefore, there is a low tolerance for undertriage with most entities recommending an acceptable undertriage level of less than 5-10% of patients [15].

Overtriage

Overtriage is defined as the inaccurate classification of a patient as high priority or acuity when their injuries are actually non-urgent [11]. A classic example of overtriage would be when a stable, non-critical patient is unnecessarily expedited ahead of sicker patients for a surgery they do not acutely require. According to Foley and Reisner, another form of overtriage is when patients with little to no chance of surviving receive aggressive medical treatment, inappropriately allocating scarce resources [13]. Compared to undertriage, overtriage represents a poor specificity and complicates triage by creating disorganization that misallocates time and resources [14,16]. In the setting of a disaster, overtriage can be just as dangerous as undertriage as this misallocation can take away scarce resources and time that could be used to save other patients. The acceptable level of overtriage is more debated, with some sources recommending 25-35% [15] and others 50-60% of patients [13].

The reason for less stringency surrounding acceptable overtriage rates is due to the influence the two rates have on each other. Overtriage and undertriage do not exist independently of one another and demonstrate an inverse relationship [13]. As overtriage rates increase and patients are treated more liberally, undertriage rates decrease as less savable patients are missed. Therefore, when faced with the decision of overallocating resources or missing a potential savable life, most entities recommend maintaining a higher allowance for overtriage in order to reduce undertriage. Previously, it was reported that 50% of overtriage was required to reduce the rate of undertriage to 0% [17], but more recently that recommendation has been decreased to 25-35% [15] due to the detrimental effects higher overtriage can have on triage efforts with minimal decrease in undertriage rates [11, 18].

However, when applying these rules to real life disaster triage, it is important to also factor in the environment and working conditions of the disaster. The amount of acceptable overtriage and undertriage in a mass casualty event should change depending on resources and casualties present [13]. For example, in a scenario where casualties are few and resources are plenty, the risks of raising the overtriage rate are outweighed by the benefit of possibly reducing undertriage as there would be little chance of running out of resources or time. On the other hand, in a grand scale disaster where resources are extremely limited, a lower overtriage rate would be acceptable, despite the possible increase in undertriage, due to the higher likelihood of running out of resources and time. Therefore, it is imperative in disaster triage to always perform an initial survey of the amount of casualties and resources available in order to form an educated plan to maximize the greatest benefit for the greatest number of people [19].

Primary, Secondary, and Tertiary Triage

In comparison to traditional triage in an ED, disaster victims are triaged multiple times throughout their medical course beginning at the site of the incident and continuing through possible admission to the ICU or OR. These multiple points of reevaluation account for the evolving nature of disasters over time in terms of resource availability, treatment delays, and injury progression or resolution [20]. Triage in the setting of mass casualties can be broken down into three different types: primary, secondary, and tertiary triage (Table 2). These different classifications differ based on the triage timing, location, and what level of care is being addressed [19, 21, 22].

Primary Triage

Primary triage occurs at first contact with patients after a disaster [22]. This can occur at the scene of the disaster, or any other setting outside of the hospital including an area away from the incident [19]. The goal of primary triage is to establish the priority of injured patients for on-site treatment and evacuation to the nearest available hospital [21]. This can also include decisions such as routing patients to trauma versus non-trauma centers or performing life saving measures in the field [7, 19]. Primary triage is regarded as the most critical stage in the disaster triage process with the greatest potential to save lives and influence population outcomes [21, 23]. As a result, many different tools and methods for primary triage have been developed and primary triage will be the major focus of this chapter [14]. The tools and specifics of primary triage will be discussed in more detail in the Triage Tools section.

Secondary Triage

Secondary triage is the second evaluation of patients’ condition and overall acuity. This occurs upon patient arrival to the hospital and commonly takes place in the emergency department [21]. However, the level of care being addressed in secondary triage changes depending on the context of the disaster and the resulting bottlenecks in ED patient care. If it is a mass casualty event involving patients with highly acute complaints such as trauma, then secondary triage will focus on prioritizing patients for initial stabilizing measures in the ED [7]. Alternatively, if the disaster takes a less acute and more extended course, such as the Coronavirus Disease 2019 pandemic, then secondary triage will focus on determining disposition of patients from the ED after the initial stabilization has been performed. The disposition prioritization can include what patients are admitted to the hospital, transferred to more specialized areas within the ED, or discharged home [19, 21]. Secondary triage is especially vital when evacuation from the site of a disaster is prolonged resulting in a large influx of deteriorating patients arriving to the hospital [22].

Tertiary Triage

Tertiary triage is the third evaluation of patients involved in a disaster taking place after initial stabilization or hospital admission. This also occurs within the hospital, but does not need to be in the ED [19]. Tertiary triage is when questions of definitive care are addressed and prioritized such as ICU admission, surgery, and other procedures including those performed by interventional radiology [21]. This final form of triage is typically performed by a physician with critical care training or a surgeon [22]. This is also a chance to reassess continued medical management of severe patients in the setting of dwindling resources such as continuing life support measures or additional treatment after poor prognostic laparoscopic findings [19]. In disasters with fewer critical patients with life threatening injuries, tertiary triage is less utilized [7].

Triage	Timing	Location	Level of Care (LOC)
Primary Triage	First patient contact	At the scene of the disaster	Determines the priority order for treatment in the field and emergency transport. Can also prioritize patients to be transported to trauma vs. non-trauma centers.
Secondary Triage	Second evaluation upon entry into the hospital	In the emergency department	Determines priority order for resuscitation in the ED and disposition after stabilization
Tertiary Triage	After initial treatment and stabilization in the ED	Anywhere in the hospital, not restricted to the ED	Determines the priority order for definitive care including ICU admission, surgery, or transfer to a higher-level facility,

Table 2: Definitions, timing, location, and level of care being decided on for the three levels of triage: primary, secondary, and tertiary [19, 21, 22].

How to Triage: Primary Triage Classification & Tools

Classification

How to properly perform primary triage in the field of a disaster has been a highly contentious area of research since before the establishment of disaster medicine [14]. In non-disaster level traumas, most medical providers in North America minimize their pre-hospital evaluation and treatment in favor of more expedient transportation to the hospital[24]. This is known as “scoop and run” and restricts pre-hospital treatment to Basic Life Support (BLS) with minimal classification of patient acuity. “Scoop and run” has been proven to have significant benefits in terms of trauma outcomes[24, 25], but more rigid triage systems are typically utilized in disasters to expedite patient prioritization, minimize uncertainty, and maximize effective use of resources to do the “greatest good for the greatest number” [26].

Globally, differing disaster triage tools and systems are implemented without any clear consensus in the literature on their efficacy [21]. However, one commonality among the majority of these systems is the four-level classification schema they use to group and prioritize disaster victims [26, 27]. First proposed by the World Medical Association (WMA), this system categorizes disaster victims into four different groups based on their acuity and how urgently they require medical intervention (Table 3) [26]. The literature labels these groups in various manners including by triage tag color (red, yellow, green, black), urgency of required treatment (emergency/immediate, delayed, minimal, expectant), or their priority level (P1, P2, P3, P4) [13, 21, 26, 28].

The immediate/emergency group consists of patients who are in critical condition, but can still be saved with immediate treatment within, at most, the next few hours. A red triage tag is commonly used to label this group [28].

The delayed patients are those who are not experiencing an imminent threat to their life, but urgent, definitive medical care will be required at some point. These patients are often labeled with a yellow triage tag [26].

The minimal group are sometimes referred to as the “walking well” or “walking wounded” and have the least severe injuries [27, 29]. These nicknames stem from the fact that most patients in the minimal group can walk following the incident. Various triage tools will even use the ability to ambulate in their algorithms since multiple studies have shown that walking following a disaster is a strong indicator of a relatively low risk patient with a good prognosis [22, 30]. These patients are labeled with a green triage tag and often require only minimal treatment that can be delayed until the rest of the patient categories have been treated.

The final category, deemed expectant, is marked with a black triage tag, and is made up of patients that are either dead or critically ill to the point that efforts to save them are deemed futile. This classification is typically made in situations where the patient’s condition is beyond treatment or when the complex treatment required to save the patient would be putting other patients at risk by misallocating already limited time and resources [21, 26]. It is important to acknowledge that this can be an especially difficult classification for providers to make. The WMA has addressed this by releasing a statement expressing that “It is unethical for a physician to persist, at all costs, at maintaining the life of a patient beyond hope, thereby wasting to no avail scarce resources needed elsewhere.[31]” However, as disasters are fluid and ever-evolving, it is the responsibility of a triage to repeatedly reassess the situation including reviewing the priority designations previously assigned to patients [28].

Table 3: Priority number, color, name, and description for the four commonly used triage tags [21, 26, 28, 30].

Tools

Despite a consensus on what priority groupings are used to sort patients during a disaster, how to place patients in each grouping is still highly divisive. The literature has been unable to provide any significant evidence for or against specific triage strategies resulting in a wide array of disaster triage systems used internationally [14, 21, 22]. In the 1980’s, formal triage scoring systems were developed for primary triage that categorized patients based on objective measures. The most used scoring systems are the Revised Trauma Score (RTS) and Champion’s Trauma Score (CTS), both of which utilize a patient’s Glasgow Coma Scale (GCS), systolic blood pressure, and respiratory rate to calculate a total score that sorts patients into the appropriate priority groupings [32]. However, triage scoring systems have been shown to not be as efficacious in the pre-hospital setting since objective measures of vital signs do not always correlate with clinical condition. As a result, triage scores have demonstrated poor sensitivity in the field and there have been instances where normal vital signs masked critical illness in disaster patients resulting in undertriage [13, 32]. Additionally, vital signs taken at the scene of a disaster are not always reliable due to various confounding variables and can create provider uncertainty in the field [32]. Therefore, triage scoring systems have fallen out of favor in disaster triage and this chapter will focus on the use of multi-tier triage algorithms.

Formalized triage algorithms are a set of rigid, pre-determined decision trees that quickly guide providers through the initial assessment of disaster victims in the field [14]. Triage algorithms base their decision making more in components of clinical presentation such as ability to ambulate and breathe rather than objective measures. These algorithms tend to be more suitable for mass casualty disasters as they minimize the time spent making active decisions and are easy to learn in a restricted amount of time [13]. The disadvantage of these algorithms is their lack of flexibility. As discussed previously in the Measures of Success: Undertriage and Overtriage section, it is important to be able to tailor your protocol, and subsequently your over and undertriage rates, depending on the number of casualties and the availability of resources. However, the rigid procedure of these algorithms does not allow for modifications of treatment criteria when time and resources are more plentiful [13]. Many algorithms have been developed with slightly different applications based on patient demographics, mechanism of the disaster, geography, etc. [14]. Due to the sheer number of triage algorithms currently available, this chapter will focus on the most used primary triage tools in disaster medicine: the Simple Triage and Rapid Treatment (START) and Sort, Assess, Lifesaving interventions, Treatment/Transport (SALT) algorithms.

The Simple Triage and Rapid Treatment (START) triage algorithm was originally developed as a result of joint efforts between a California Fire department, Marine department, and medical providers in 1983 [33]. This was one of the first triage systems developed outside of the military and, following its conception, the Domestic Preparedness Program of the Department of Defense made it standard practice in disaster events [28]. It is now the most prolific mass casualty triage system used in the United States [27].

The START triage algorithm was designed as an expedient triage system that would be easily teachable to emergency providers with minimal training [26]. The objective of the system is the be able to evaluate patients older than eight years old within 30-60 seconds and triage them into one of the four priority groupings discussed previously: immediate/emergency (red), delayed (yellow), minimal (green), expectant (black) [14, 27]. This is accomplished through strict criteria looking at patient ambulation, respiratory rate, radial pulse, mental status, and capillary refill, though many versions of START no longer assess capillary refill due to variabilities from the environment [13, 22, 33].

As depicted in Figure 5, the initial step of START is to prompt patients to walk [27]. If a patient can walk following a disaster, this has been shown to be an indicator of low risk and good prognosis [22, 30]. Therefore, patients who can walk are immediately classified as minimal, green, or priority 1. Following this initial step, the remaining non-minimal patients are evaluated based on their respiration, perfusion, and finally mental status. Examples of methods used to assess mental status during START triage include asking patients to perform simple command such as opening and closing their eyes or squeezing a hand [34]. A Yellow tag or delayed status is assigned to all patients that were not originally deemed minimal, but meet the respiratory, perfusion, and mental status criteria set by START. An easy mnemonic to remember the parameters looked at by START is “RPM:30-2-can do”, with RPM standing for Respiration,Perfusion, Mental status. The second portion “30-2-can do” are the associated cut off values for each category: > 30 respirations per minute, presence of radial pulse or capillary refill <2 seconds, and can follow simple commands [26, 27].

Figure 1: START Algorithm to triage patients based on severity [22, 28].

Though there is little research analyzing the overall efficacy of START, the triage system has demonstrated higher overtriage rates in more critically ill patients during a disaster [28]. In a study by Kahn et. al, START was shown to have an overall accuracy of 44.6% in assigning the correct acuity level for patients. Upon further analysis, START was shown to perform well when identifying patients in the minimal category, with the walk test demonstrating accurate prognostic predictions [35]. However, the triage system experienced higher levels of overtriage (53.38%) in the two more critical patient categories with a significant number of patients inappropriately being placed in the immediate/emergency classification when they belonged in the delayed category [35].

The Sort, Assess, Lifesaving interventions, Treatment/Transport (SALT) algorithm was designed to unify the many existing triage algorithms. Due to a significant lack of research surrounding the efficacy of these triage tools, the Center for Disease Control and Prevention (CDC) assembled a committee in 2008 to combine the most effective features of the current mass triage algorithms into a national standard [22, 28]. This resulted in a new triage algorithm that is very similar to START, but with some key differences. SALT performs a more comprehensive triage of patients of all ages by performing multiple stages of sorting and prioritization with opportunities for reassessment [27]. Additionally, SALT prioritizes life-saving interventions by incorporating them into the triage algorithm leaving less room for hesitancy and uncertainty [13]. The protocol and unique features of SALT can be further elucidated by breaking down what SALT stands for.

Sort refers to the first step, unique to the SALT protocol, which entails an initial sorting of patients into three groups, prior to formal evaluation, to determine what order patients should be clinically assessed. This pre-sorting is based on their ability to ambulate and perform simple commands (Figure 2) [36]. If patients are able to ambulate, then they are placed in the “Walk” or “Able to walk” group. These patients will be assessed last due to the low risk associated with the ability to ambulate [22, 30]. Patients who are unable to walk, but are able perform purposeful movements such as waving will be placed in the “Wave” or “Able to make purposeful movements category” and assessed second. Finally, patients who have obvious life-threatening injuries or remain still despite prompts to walk or wave are placed in the “Still” or “Severely injured” category. These patients will be clinically evaluated first [27].

Figure 2: Step 1 of SALT algorithm to prioritize who to clinically assess first [22, 27, 28].

The Assess and Lifesaving interventions steps come next and are performed almost simultaneously. Assessrepresents the clinical evaluations that are performed after the three priority groupings have been established during the Sort step. This step is looking for any life-threatening injuries that require immediate stabilization [14]. As threats to life are found during this evaluation, the Lifesaving interventions step calls for immediate medical intervention during triage to stabilize these patients. These interventions typically include opening the airway, hemorrhage control, needle thoracostomy for pneumothoraxes, and antidote auto-injection for poisoning [14, 22].

The last phase of SALT, Treatment/Transport, requires an additional evaluation of patients following lifesaving interventions in order to place patients in the same four priority classifications for evacuation and definitive treatment utilized in START (Figure 3). This step affords the triage an opportunity to reassess patients following life-saving interventions and factor in their response [14]. This reassessment involves many of the same parameters looked at in START including breathing, mental status, and peripheral pulse. However, it also includes a step to consider the patient’s condition in the setting of the resources available [22]. Similar to START, once the patients have been sorted and tagged, they are transported and treated according to their priority group.

Figure 3: Step 2 of SALT algorithm [31, 36, 37].

SALT has taken over as one of the major triage algorithms used in disasters and is endorsed by numerous entities including the American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, American College of Emergency Physicians, and more [36]. Studies have already begun to show that SALT provides more accurate triaging when compared to START and other triage systems [37, 38]. On the other hand, some studies have observed high levels of overtriage in SALT, similar to those seen in START, and even instances of high undertriage [28, 37, 38]. However, it is important to keep in mind that no clear conclusions can be drawn regarding SALT’s efficacy until more research is performed.

Summary

Disaster Medicine Triage focuses on managing medical care during events that overwhelm local emergency departments, necessitating additional aid. Definitions of “disaster” have evolved to describe situations beyond a community’s coping capability, encompassing natural and man-made incidents like water contamination and power outages. Emergency Medicine, among other healthcare disciplines, plays a crucial role, particularly in disaster response coordination and triage, aiming to do the best possible care for the greatest number. Triage, a core component, involves sorting patients based on their medical needs versus resource availability. With mass casualties, effective use of resources becomes inevitable, underpinning the need for efficient triage to optimize care and resource allocation, emphasizing the utilitarian principle of maximizing survival on a population level.

Authors

Parker MADDOX BA, MS

Parker Maddox is a fourth-year medical student at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia. He graduated from the University of Virginia with a double major in Biology and Chemistry and went on to obtain a master’s degree in Biophysics and Physiology at Georgetown University. Since arriving to medical school, Parker has developed a passion for Emergency Medicine and has performed research on a wide range of topics including early sepsis recognition, pandemic viruses including Coronavirus 2019 and Monkeypox, ischemic stroke, Bell’s palsy, and international ECMO critical care protocol. This work has yielded multiple publications and a presentation at the Society for Academic Emergency Medicine (SAEM) 2022 Conference.

Hassan KHURAM BS, MS

Hassan Khuram is a 4th year medical student at Drexel University College of Medicine, with a background in psychology, biotechnology, and business of healthcare. He graduated Magna Cum Laude with a Bachelor of Science in Psychology from Virginia Commonwealth University and a Master of Science in Biotechnology from Georgetown University. He is passionate about neurocritical care, medical education, and bioethics. He has an extensive background in research, having conducted studies on various subjects, including substance misuse, Parkinson's disease, mindfulness meditation and more. He has published articles on neurological emergencies and ethical issues in neurological care.

Scott GOLDSTEIN, DO, FACEP, FAEMS, FAAEM, EMT-PHP

Dr. Scott Goldstein started his medical career at New York College of Osteopathic Medicine in New York where he received his Doctorate of Osteopathy and continued his training at Einstein Healthcare Network in the field of Emergency Medicine, Philadelphia. Dr. Goldstein is dual-boarded through the American Board of Emergency Medicine in Emergency Medicine and Emergency Medicine Services (EMS). He currently works at a Level 1 academic trauma center, Temple University Hospital, in Philadelphia where he is the Chief of EMS and Disaster Medicine. He has continued to be an active member of the education community and EMS community where he holds the title of Fellow of American College of Emergency Medicine through ACEP, Fellow of the Academy of Emergency Medical Services through NAEMSP and Fellow of the American Academy of Emergency Medicine through AAEM. His current academic title is one of Clinical Associate Professor of Emergency Medicine at Lewis Katz School of Medicine at Temple University.

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Arif Alper Cevik, MD, FEMAT, FIFEM

Being a team member/leader and team dynamics in ED (2024)

March 30, 2024April 22, 2024 ~ iEM Education Project Team ~ Leave a comment

by Munawar Farooq & Bret Nicks

Introduction

Emergency care worldwide has organizational and regional nuance, mainly due to differences in healthcare systems, infrastructure, resources, and history. However, the team’s value proposition remains critical for success in all emergency departments. Over the past several decades, it has become evident that teams and teamwork can positively impact many aspects of the care environment and the engagement of those serving there. When we consider the myriad challenges impeding quality decision-making in the emergency department (ED), such as a lack of time, evolving information, chaotic environment, limited resources, and constant interruptions, amongst others, having a dedicated team can make a significant difference.

While the concept of a team is not new, our understanding of the value proposition of a team and the attributes of effective teams continues to evolve. For many of us in medicine, working in a group is expected. However, there are distinct differences between working in a group and being part of a team. What differentiates a team from a group is the commitment to a common purpose, shared desired outcomes, collaborative and complementary approach, value team over self, and shared accountability. A team’s foundation develops from those that collaborate around a shared goal. However, successful Emergency Medicine (EM) teams require a broader understanding of the essential attributes, processes, and expectations needed for a highly variable, chaotic, intellectually challenging environment dedicated to exceptional patient care. For these reasons and many others, EM epitomizes the ideal of team sports in healthcare.

Psychology of Team

Team dynamics are the learned, unconscious psychological forces influencing a team’s behavior and performance. Organizational culture and departmental culture significantly affect team dynamics. Further influencing factors include the nature of the work, the work environment, work relationships within and across teams within the department, the level of perceived support, and the work effort itself.[1] Recognizing the challenging environment of acute and emergency medicine, awareness of and creating an integrated and positive team dynamic is essential. High-functioning teams demonstrate better clinical outcomes, increased team retention, increased wellness, higher resiliency, and better comparative financials.

High Performing Team Characteristics

Characteristics of successful teams and team members have been studied extensively in various professions ranging historically from the aviation industry to more modern companies like Google. [2] The aviation industry mandates that the flight and cabin crew work together as a team using standard operating procedures (SOPs) and formal training to facilitate teamwork and communication. They recognize that cognitive and psychological stressors can lead to human errors that can occur in high-stakes environments.

Looking at a very different workplace, researchers at Google asked what makes a (Google) team effective. While they anticipated finding the mix of those on the team to be the most influential on the team’s success, they found that the way team members interacted with each other mattered more than the composite of the team [1]. While competency requirements exist in EM and other clinically-based teams, much of Google’s findings apply. They identified five characteristics that promoted effective teams: psychological safety, dependability, structure, clarity, meaning, and impact (Figure 1).

Figure 1: Characteristics of Highly Functioning Teams.

Adopted from Rozovsky J. The five keys to a successful Google team. 2015. URL:
https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team/

Although EM is not Google, recognize that the foundation of all highly effective teams remains the same: trust. In the 5 Dysfunctions of a Team, Lencioni states that you cannot have a successful team without trust. Further, with a lack of trust, team members fear engagement in healthy conflict, essential to reaching better decisions and team member commitment. Only committed team members can hold each other accountable so that the team remains focused on collective goals (Figure 2).

Figure 2: Lencioni, Patrick. The five dysfunctions of a team. London: Wiley, 2002

In emergency medicine (and perhaps medicine in general), metrics and outcomes are commonly the focus of many teams. While quality, safety, and administrative outcomes are essential, one should recognize that top performance of these outcomes flows from teams built on trust, embracing conflict, commitment to a common goal, and shared accountability. When these are in place, quality metrics follow. Addressing team dysfunctions takes work. It requires a desire for positive change, courage, and creating team alignment.

Further, emergency medicine teams are dynamic interdisciplinary teams working in a constantly changing environment with highly fluid teams of junior and senior emergency physicians, nurses, other specialists, students, residents, and other medical assistants. With so many variable team inputs, solidifying the departmental culture and creating the expectation for and practice of highly functional teams helps ensure that any patient receives safe and efficient healthcare, meeting high-quality standards without fail regardless of date, time, and acuity of presentation.

Literature on high-performing teams across multiple professions supports these and additional common characteristics. Dr Tim Baker, in his book ‘Winning Teams’ presents eight characteristics of Winning Teams, as shown in Figure 3.

Figure 3: Adopted with permission Winning Teams, Dr. Tim Baker. Used with copyright permission from DBOS. 8 Key Characteristics of a High-Performing Team | by DBOS AU | Medium

Fulfilling this model, our emergency room teams are diverse but flexible. We adopt safe and effective working procedures like cognitive aids and structured communication tools. We aspire to achieve a shared goal of efficient and safe patient care. We create teams that build trust and mutual respect through transparent communication and clear leadership. We accomplish this by continuously learning and practicing together the necessary clinical skills and critical human factors.

Team development and its success are predicated on a supportive culture that recognizes a just cause. For high-performing organizations, that culture is well-established across all departments and levels. Regardless, organizational culture is simply what you see when you watch and experience the service provided. It comprises a complex pattern of values, expectations, ideas, attitudes, and behaviors around a shared goal.

Effective Emergency Team Leadership

One key challenging but rewarding role of the emergency physician is to orchestrate and lead diverse teams in a relatively stressful and unpredictable environment. While this may represent one of the major attractions of the emergency physician, it can be daunting for some. For a junior physician, it is essential to identify good leadership attributes early and apply them continuously, as it benefits the team and a leader’s clinical navigation during resuscitation. Something can be learned from every member of an interprofessional resuscitation team. Observing how they serve as role models and clinical leaders in any situation and how they interact with colleagues, patients, and families provides a basis for personal growth and reflection.

Advanced life support simulation studies identified better outcome metrics (higher quality cardiopulmonary resuscitation with better technical performance, shorter pre-shock pauses, with lower total hands-off ratio, and shorter time to first shock) with teams having leaders with more experience and refined leadership attributes. [3] Although variability exists with healthcare leader experience, having a high-performing team enhances team dynamics and outcomes. Regardless, effective team leaders must embrace and demonstrate the following leadership elements:

Understand the team value proposition and roles of its members
Manage well in challenging and changing situations
Effectively communicate
Embrace mutual accountability and responsibility
Set specific goals while persevering to achieve them
Balance individual tasks and promote teamwork
Build solid connections and relationships
Demonstrate adaptive learning from their experiences.

It is important to note that most of these attributes are not related to knowledge and skills commonly taught in medical schools but rather experientially or intentionally developed emotional intelligence skills. Developing and deploying these elements can positively influence everyday tasks performed by emergency physicians, such as:

Organize the team and resources to maximize performance
Articulate clear goals with delegation of tasks
Make decisions through the collective input of members
Empower team members to speak up and challenge the leader when appropriate, using group norms to guide behavior
Actively promote and facilitate good team processes
Skillfully prevent and resolve any conflict

Although historically called soft skills or abstract skills, data would suggest that these critical leadership skills are as necessary as clinical competencies. Effective leaders not only work on their clinical and content competence but also on emotional intelligence, communication skills, and performance under pressure.

The Team Player

What makes a team player exceptional? When you think about your current team(s), are they made up of ideal team players? If not, what are you doing about it?

While exceptional team leaders can navigate the professional nuances of their team members, the team’s success is often limited by the leader’s capacity and by the attributes of those team members. High-performing teams are far more multiplicative rather than the simple sum of individual member performances. How we identify future team members or invest time and effort into developing current team members impacts not only outcomes but also influences the quality and capacity of the team.

Often, we hire team members based on their clinical competencies, educational accomplishments, and career success. However, moving beyond competence to team and organizational cultural alignment is essential as we look more closely at developing high-performing teams. Leaders must identify and employ people with three traits that all good team players share: humility, hunger, and smart people (interpersonal intelligence). In his book, “The Ideal Team Player,” Lencioni recommends considering aligning the essential virtues of a team player into three characteristics:

Humble (not arrogant or ego-centric; team-focused)
Hungry (great work ethic; never settling for the minimum)
Smart (skilled in emotional intelligence and people skills)

The ideal team player must have all three characteristics to be a trusted and proficient team member. Assessing teams requires self-reflection regarding these three traits, a conscious desire, and a focused effort to improve. Awareness and growth in this area catalyze individual and team success. When only one or two of these attributes are present, team leaders must consider the value proposition of developing these team members or identifying other opportunities that might be better for that team member.

Key Principles of Teamwork

In addition to discussing the psychology of teams, attributes of high-performing teams, effective team leadership, and ideal team players, further studies have looked at systematic approaches to creating a culture of teamwork within healthcare. TeamSTEPPS, an educational program about teamwork, highlights the fundamental principles of an effective team structure, clear communication process, transforming leadership, situational awareness, and mutual support. [2]

Leaders use Delegation, Pre-Brief and Debrief, and Group Huddles in effective teams to clarify team goals, roles, and expectations. Both team leaders and members maintain situational awareness, cross-monitor each other, and provide constructive feedback. Everyone uses structured communication tools like SBAR (Situation, Background, Assessment, Recommendation), Checking Back, Advocacy, and Gradual Assertiveness to communicate clearly and deliver the safest and best possible care.

Practical Tips to Improve Teamwork

Understanding the attributes of high-performing teams, team leaders, and team members considering the challenges of emergency medicine is foundational to change. However, identifying practical applications that begin to create change and further support culture is essential. [5] Below are some typical applications that have been suggested in the literature and through clinical experience:

Department awareness: Before you start working in a new department, visit, observe, identify the culture, and ask yourself how you can be a catalyst.
Bring your clinical competence and communicate medical decision-making with your team.
Developing empathy in daily challenges requires intentionally understanding another’s perspective, avoiding early judgment, recognizing inherent emotions, and responding genuinely to that emotion. (Brene Brown)
Understand and set role expectations while understanding how your personal attributes influence how you perceive your role.
Huddle first, then get started. Know your team – names and roles. Set expectations for team goals and find opportunities to engage and communicate in person with colleagues throughout the shift.
Consider the patient and their family an essential and valuable team member. The ‘nothing about me without me’ principle applies to everyone, including the patients and staff.
Lend a helping hand. Look for such opportunities and do not wait for the request.
Self-reflection increases continuous learning and improvement. Make it a regular practice regardless of the outcome or situation.
In any resuscitation or other emergency team management situation, follow the principles of clear roles, closed-loop communication, task focus, situational awareness, and the courage to speak up if required for patient or staff safety.
Listen actively by paying attention to non-verbal clues and perspectives while being aware of your own. Listen to understand – do not listen to respond.
Avoid negatively inferred language that feigns responsibility and creates blame or division. This rapidly erodes teamwork and a supportive culture.
Handoffs matter. Align your approach and expectations, as this directly impacts patient and team outcomes.
Offer compliments and appreciation genuinely and frequently. Recognize a job well done with gratitude. It reinforces positive effort and builds team rapport.
Build relationships outside the work environment when feasible. Know your colleagues through their interests, values, goals, achievements, and challenges.
Advocate for patient safety. Learn how to challenge a team member or leader if there is any concern for patient safety. Use a structured tool like “CUS” (Figure 4) or simply state, “I have a concern.”
Never think you are alone. Help is always available. Working in the emergency department is not easy – recognize it. If you need assistance, clinically or personally, ask.

Figure 4: CUS, graded assertiveness tool. Source: TeamSTEPPS. https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html

Case Scenario Application of Team Dynamics

Let us apply all the above learning to a resuscitation scenario and understand how a resuscitation team works. You are part of a resuscitation team when EMS encodes that they are bringing a 10-year-old boy whose scooter was hit by a car. The suspected injuries include a head injury and a possible right thigh injury. The trauma resuscitation team manages the patient very well through the following teamwork processes:

Pre-arrival

Assigned roles. The assigned team leader knows the team members’ strengths, limitations, and expectations. Every member acknowledges their assigned role and any concerns or needs they may have. Doing so before the patient’s arrival helps mitigate positional limitations during the resuscitation. Any members outside this team are also informed as required according to local resources, e.g. Radiographer, Pediatric Surgeons, Orthopedics, etc.
Environment and equipment are prepared with enough space to work around. Airway and resuscitation equipment, confirmed at the beginning of the shift, is assessed based on any specified checklists and procedures.

Post Arrival

On arrival of EMS, handover is taken using pre-defined handover tools or processes with prehospital teams. The noise and distractions are kept to a minimum to optimize patient care information handoff and prompt transfer.
The team leader directs care with the team – and, when possible, stands at the foot of the bed to maintain situational awareness and monitor the team’s performance.
Team members perform assigned roles while maintaining situational awareness, monitoring the patient and teammates, and reporting back.
Clear and respectful closed-loop communication. Team leaders direct requests to every member using their names, and team members acknowledge the understanding of the task by repeating back and then announcing the completion of the task.
The team leader frequently shares ongoing medical decision-making with the team throughout the resuscitation by describing the situation and plan. For example, after completion of the primary survey, the team leader announces, “It appears that the child has an isolated head injury. Let us aim to intubate this patient and transport him to a CT scan within the next 15 minutes”. This provides directional clarity and offers an opportunity for feedback.
Teams use cognitive aids like checklists to prevent any medical errors. In contrast, the team leader maintains an open, respectful, and empowering environment where every member can challenge and raise patient safety concerns. Team members use graded assertiveness tools like ‘CUS’ to raise their concerns.
A culture of vulnerability and trustworthiness is maintained when team leaders or team members express when they are unsure of something and freely ask for help or a second opinion. Before any significant high-risk decision, the team leader shares the medical decision-making rationale and plan with the team.
Updating or briefing new members from other teams by the team leader or a designated member allows for clarity of ongoing care and consultative expectations. Recognize the emergency department is your home, but that may not be true for others.
After resuscitation, a hot debrief is performed with the team to express objective gratitude, provide compliments, discuss what went well, and identify areas for improvement. Critical issues should be addressed in a more formal debrief, especially if future application is intended.

As mentioned throughout this chapter, the benefits of developing a high-performing team in the emergency department are myriad. It will improve departmental morale and greatly influence the quality of care provided, create mission alignment, foster resiliency, and attract exceptional team members. Table 1 presents additional benefits of effective teamwork [6].

Organizational benefits	Team benefits	Patient benefits	Benefits to team members
Reduced time and costs of hospitalization	Improved coordination of care	Enhanced satisfaction with care	Enhanced job satisfaction
Reduction in unexpected admissions	Efficient use of healthcare services	Acceptance of treatment	Greater role clarity
Services are better accessible to patients.	Enhanced communication and professional diversity	Improved health outcomes and quality of care, reduced medical errors	Enhanced well-being

Table 1: The benefits of effective teamwork

Summary

Successful teamwork is challenging but worthwhile. Trust represents the foundation of all successful teams. They also embrace a shared common purpose and a dedication to quality in an environment where team members work together, communicate effectively, anticipate and meet each other’s demands, and inspire confidence, resulting in coordinated collective action. For many, the phrase, ‘teamwork can make the dream work,’ resonates with them. It is an uphill climb. It starts with trust. It requires courage. And it requires effort. If the dream is high-quality patient care in a safe and respectful department, start with your team.

Authors

Munawar FAROOQ

Dr. Munawar Farooq, with qualifications including MBBS, FCPS (Pak), MRCS (UK), FACEM (Australia), and a Pg. Dip. in Medical Toxicology from Cardiff University, UK, is currently an Assistant Professor of Emergency Medicine at CMHS, UAEU. His prior roles include Consultant in Emergency Medicine in Canberra, Australia, and Doha, Qatar, Clinical Lecturer at Australian National University (ANU) in Canberra, ACT Australia, and Honorary Senior Lecturer in MSc Resuscitation at Queen Mary University London, UK. His special interests are in resuscitation medicine, toxicology, trauma, and medical education. His research focuses on detecting deteriorating patients, early warning scores, oxygen delivery device requirements in COVID outbreak, on-floor low fidelity simulations, and Leadership Training. In medical education, he is particularly interested in teaching leadership skills, Emotional Intelligence, and Human factors.

Bret NICKS

Bret Nicks, MD, MHA is an emergency physician that embraces the breadth of our specialty. He is a Professor and Executive Vice Chair of Emergency Medicine at Wake Forest University School of Medicine. He is the past president of the North Carolina College of Emergency Medicine. He served as the Chief Medical Officer of the award-winning Wake Forest Baptist Davie Medical Center. Dr. Nicks served as the founding Associate Dean for the Wake Forest Office of Global Health. He has lived, practiced, and led in many resource austere locations globally, although calls the academic tertiary care emergency department his home. He is passionate about, consults and lectures on the interface of clinical quality, leadership and team culture – and is dedicated to developing EM leaders for the future of our specialty and the transformation of healthcare. He loves anything outdoors, enjoys blogging on various life and leadership topics; http://www.bretnicksmd.com/blog, and recently published his first book.

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References

Rice MM. Strategies for clinical team building: the importance of teams in medicine. Emergency Department Leadership and Management: Best Principles and Practice. 2014 Nov 27:47
Rozovsky, Julia. “The five keys to a successful Google team. 2015.” URL: https://rework. withgoogle. com/blog/five-keys-to-a-successful-google-team (2015).
Yeung JH, Ong GJ, Davies RP, Gao F, Perkins GD. Factors affecting team leadership skills and their relationship with quality of cardiopulmonary resuscitation. Crit Care Med. 2012;40(9):2617-2621. doi: 10.1097/CCM.0b013e3182591fda
Clapper TC, Kong M. TeamSTEPPS®: The patient safety tool that needs to be implemented. Clinical Simulation Nursing. 2012;8(8):367-373
Vazquez CE. Successful work cultures: recommendations for leaders in healthcare. Leadersh Health Serv (Bradf Engl). 2019;32(2):296-308. doi:10.1108/LHS-08-2018-0038
Babiker A, El Husseini M, Al Nemri A, et al. Health care professional development: Working as a team to improve patient care. Sudan J Paediatr. 2014;14(2):9-16.

Free online resources for further self-learning

CanadiEM Frontline Primer, Emergency Department Culture 101. https://canadiem.org/canadiem-frontline-primer-emergency-department-culture-101/
Rozovsky J. The five keys to a successful Google team. 2015. URL: https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team/
Lencioni P. The 5 Dysfunctions of a Team. Teamwork 5 Dysfunctions | The Table Group
Pocket Guide: TeamSTEPPS https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html
Podcast; Dr. Randy Sorge with Dr. Ryan Stanton, Teamwork makes the dream work – Team Dynamics in the ED. https://music.amazon.com/podcasts/816785e7-0c23-47c0-96f4-38017c4b11ba/episodes/6a12c8fd-71f1-4b64-8274-ea72e4189fe3/acep-frontline—emergency-medicine-teamwork-makes-the-dream-work—team-dynamics-in-the-ed

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Discharge Communications (2023)

May 15, 2023May 18, 2023 ~ iEM Education Project Team ~ Leave a comment

by Dominique Gelmann, Bret Nicks

Introduction

The process of emergency department (ED) discharge provides critical information for patients regarding the next steps of their care. Discharge instructions are often required by hospital accreditation and governmental organizations for quality or monitoring metrics. However, studies show that many patients do not fully understand or recall the instructions they receive [1,2]. In addition to patient-specific factors contributing to lack of comprehension and care compliance, the myriad situational challenges inherent to every emergency department as well as individual clinician skills and knowledge of best discharge practices further impact patient experience, understanding, and subsequent outcomes.

In many instances, the discharge process is often limited to a brief exchange of documents, prescriptions, and verbal description of the diagnosis, frequently leaving patients with uncertainty about their care plan. Understanding discharge instructions can be very challenging for a variety of reasons. Physical or emotional discomfort can impact receptiveness to and comprehension of imparted information, for example. Patients or family members eager to leave may be less interested in the instructions; conversely those presented with a devastating diagnosis may be less able to process specific details.

Moreover, a significant number of patients have low literacy and/or health literacy levels. In addition, the busy ED setting may distract the patient’s attention from such instructions. Understanding the challenges surrounding discharge communications in the ED from the patient’s perspective and having a clear approach and purpose is essential. Much more critical than an afterthought, discharge is the first step of a patient’s care transition and greatly impacts quality outcomes, litigation, experience, and team morale [3,4].

Understanding the Challenges

Emergency physicians face unique challenges while ensuring high-quality care due to distractions and time limitations that are common throughout ED settings. In most cases, emergency physicians have little or no previous knowledge of their patients and are unlikely to partake in the follow-up process, making effective communication paramount when patients are discharged from the ED. Providing clear and consistent communication throughout the entire patient care encounter, including the discharge process, is an important aspect of quality and patient-centered emergency medical care.

Unfortunately, many patients are discharged from the ED with an incomplete understanding of the information needed to safely care for themselves at home or when to promptly return to the ED [1, 5-6]. Patients have particular difficulty comprehending post-ED care instructions regarding medications, home care, and follow-up expectations. And while all patients discharged from the emergency department should be provided instructions for ongoing management of their medical condition, studies demonstrate that patient recall and understanding of diagnosis, treatment, and follow-up plan are generally quite poor [1,2,5-9]. This raises significant concerns for care plan adherence and medical outcomes, which studies show are poorer in cases of low health literacy. Given current trends toward value-based care and the fact that nearly half of the lawsuits in emergency medicine revolve around discharge instructions and plans, ongoing improvements in the discharge communication process is essential [3,4].

While some of this relates heavily to the ability of the provider to establish a trusting and positive patient-provider relationship within the ED constraints, several additional strategies can be used to enhance the recall of instructions, improve compliance, and minimize litigation.

Discharge Essentials

Effective discharge communication provides an opportunity for the emergency department team to summarize a patient’s visit, teach them how to safely care for themselves at home, and provide specifics regarding the next steps in their care process. It also gives ED physicians a chance to address any remaining questions or concerns, often augmenting patient and family understanding while improving care plan retention. Although patient education at discharge typically begins with initial assessments and conversations with patients and family, other factors can also influence the success or failure of how information is transmitted at discharge.

Common interventions promoting an effective ED discharge process include using a standardized approach to relaying content, providing various modes of information delivery and tailoring them to the individual patient, confirmation of comprehension, post-discharge care follow-up planning, review of vital signs, and a patient-centered closure (Table 1) [8,9].

Table 1: Interventions in the ED Discharge Process

Domain	Intervention
Content	Standardize approach
Delivery	Verbal instructions (language and culture appropriate)
	Written instructions (mindful of lower literacy levels)
	Basic Instructions (including return precautions)
	Media, visual cues, or adjuncts
Comprehension	Confirm comprehension (teach-back method)
Implementation	Resource connections (Rx, appointment, durable medical supplies, follow-up)
	Medication review

Content refers to the education provided to our patients related to their ED testing, procedures, and treatment, as well as further education on diagnosis, expected course of illness, post-ED treatment and follow-up plan, and medication reconciliation. Instructions should specifically highlight time-sensitive next steps in care plans, including when and how to schedule follow-up appointments with whom and why. Further, emergency physicians should assist in arranging critical follow up prior to discharge as able. Precautions regarding when to return to the ED versus waiting for any follow-up appointments should additionally be provided, as well as instructions for how to care for oneself until follow-up. These basic tenants of discharge, often described as the ‘rules of the road’ (Table 2), may serve as a basic framework for the discharge process.

Table 2: Rules of the Road for Successful Discharge

Have the right diagnosis
Time & Action Specific Instructions
- What to do
- When to do it
Provider Specific
- Who to contact
- Why and When
- Printed Information
- Verbally explained
- Verbally confirmed

In addition to the content itself, the importance of the quality and approach of its delivery cannot be overstated. The ED provider and care team members must consider the wide range in literacy, health literacy, cultural backgrounds, and access to outpatient resources when delivering the ongoing care instructions [6,7]. In many instances, EDs attempt to improve patient and family understanding of discharge instructions through standardization and simplification of written and verbal instructions. Due to literacy variability, current literature recommends instructions are written at a late elementary educational level [10]. Verbal discussions in conjunction with written instructions have been shown to be superior to written instructions alone [11]. For patients with a primary language differing from that of the clinician, use of interpreter services, when available, has been shown to improve quality of discharge communication and clinical understanding [12]. Other approaches that may benefit patient outcomes include providing supplemental written information and using visual and multimedia adjuncts to support understanding [8,9].

Essential to any successful approach is the comprehension of the patient regarding all of the information provided. After all, if the content and delivery are exceptional but the comprehension is poor, this should be seen as a discharge failure as it decreases care compliance and outcome quality. To address this specific aspect of the discharge process, instituting a read-back or teach-back method is recommended. This method involves asking the patient to repeat back their understanding of the information imparted, which allows the physician to identify any remaining gaps in understanding and provide additional instruction as needed.

The implementation of discharge care processes frequently falls short due to unidentified social and medical factors that prevent the plan from being carried out. Social factors could include homelessness, low income, uninsured/underinsured status, lack of transportation, or lack of primary care. Medical factors could include concurrent psychiatric illness, substance abuse, cognitive impairment, inability to care for self, or young/advancing age. Understanding these circumstances will help identify patients at high risk for discharge complications and trigger additional resource considerations for these patients.

The discharge process provides an opportunity to ensure the patient’s condition is well understood, that no additional medical red flags need to be addressed, and that the care plan and follow-up are well understood. In an online video, Dr. Oller provides another process to engage the ‘moment of safety‘ related to discharge and outlines 5 essential steps (Table 3) for any ED discharge [13].

Table 3: ED Discharge: Moment of Safety

Has the medical provider discussed the findings, diagnosis and plan of care (including medications and follow-up plan)?
Confirm the discharge instructions and prescriptions match the patient identifiers
Review all prescriptions and clarify any changes
Review current vital signs
Provide closure

Barriers to Successful Discharge

The barriers to successful discharge are myriad. Some are intrinsic to the ED work environment and nature of emergency department patient arrival and flow. Others relate to the challenging or often unidentified social and medical factors that prevent the plan from being completely carried out. In a recent American College of Emergency Physician Quality Improvement and Patient Safety section meeting, Dr. Pham shared a conceptual framework for understanding the barriers to success and improving the discharge process (Figure 1) [14].

Figure 1: Barriers to Successful ED Discharge

While this framework may not be uniformly representative of all EDs, it addresses many of the operational failures that occur outside of the ED and outlines opportunities for hospitals and health systems to align for improved patient care outcomes. And while screenings for high-risk discharges in EDs occur, the additional resources needed to ensure appropriate social work or case management care coordination are often limited.

Post-discharge follow-up processes for patients at risk for failing discharge instructions exist in some systems. This may include flagging a patient’s chart for a social work follow-up to assess and assist with the patient’s ability to obtain necessary medications, make and attend follow-up appointments, or address other concerns identified by the provider. Some physician groups routinely call patients the next day to see how the patient is doing and ensure understanding of their discharge instructions and care plan [7,8].

Types of Discharge Information Packets

Discharge instructions vary widely by practice location and resources available. However, there remain 3 primary means of providing discharge information and instruction: a basic care instruction note, a preformatted illness specific instruction sheet, and a templated software-based discharge product [8].

Commonly used, an instruction note is simply a set of instructions handwritten or typed on plain paper, without the assistance of computer programs. In settings with limited resources, this may be the only means of providing essential care information for the patient, their family, and the provider with whom they may follow-up. While uniquely tailored, they may lack substantial content for care, take time to prepare, and be limited by literacy and handwriting.

Information sheets are pre-printed education and instruction documents that describe care information related to one specific illness. They can be developed for the most common medical illnesses for each institution and have essential information regarding plans of care. Information sheets are immediately available, inexpensive, reproducible, and can be designed to include simple language and or pictorial education. They are not patient specific, may not provide adequate instruction in difficult or complicated cases, and require computer, printer, and copying capacity.

For settings with an integrated EHR, software products that create discharge packets (including discharge diagnoses, medications, medical care instructions and information regarding the illness, outlined care course after leaving the ED, and essential contact information for those next steps) are available. These are highly resource dependent and therefore may not be routinely available.

Each form of written discharge materials offers its own unique benefits and drawbacks. Regardless of type utilized, physicians should exercise the basic principles outlined above in ensuring appropriate readability and quality of information provided. While specific details are helpful and important, distilling instructions into a short, high-yield sheet has been shown to be more effective than providing a large stack of superfluous [information] that patients may not entirely review [15].

Leave Against Medical Advice and Elopement

In certain circumstances, patients may request to leave prior to completion of their medical evaluation and treatment. In this situation, it is essential for the last health care professional caring for the patient to clearly document why the patient left and attest that the patient had the mental capacity to make such a decision at that time. While some electronic documentation systems have templates in place to assist with this documentation, Table 4 provides basic information for against medical advice (AMA) discharge documentation that can be used to create a uniform template [3,4,16,17].

Table 4: Documentation for Patients Leaving Against Medical Advice

Component	Description
Capacity	Establish a patient’s decision-making capacity, and clarify aspects of care which may affect capacity (i.e. patient is now clinically sober, etc.)
Risks	Specific condition-associated risks that were discussed (missed diagnosis, potential harms from untreated disease process, etc.)
Verify comprehension	Patient’s understanding of the risks
Patient’s decision	Include the patient’s decision, and any alternative plans (i.e. patient refused admission, but agreed to follow up with the primary physician tomorrow)
Signatures	Patient’s and provider’s signatures

An attempt should be made to provide the patient with appropriate discharge instructions, even in the event that a complete diagnosis may not yet be determined. Include advice for the patient to follow up with their own physician, strict return precautions, and concerning symptoms that should prompt the patient to seek further care. In addition, it should be made clear that leaving against medical advice does not prevent the patient from returning to the emergency department for further evaluation if their symptoms worsen or if they change their mind about receiving care. Despite a common notion to the contrary, AMA discharge does not automatically provide the emergency physician with immunity from potential medical liability [16,17]. In the event that a patient lacks decision-making capacity to adequately understand the rationale and consequences of leaving AMA and their condition places them at risk for imminent harm, involuntary hospitalization is warranted and often legally required depending on the location of practice. In unclear circumstances and if available, a psychiatrist can assist in determining capacity, especially in the case of patients with mental health conditions.

Elopement is a similar process in which patients disappear during the care process. While it is difficult to provide discharge paperwork for these patients, documenting the actions taken to find the patient is essential (e.g. searching the ED, having security check the surrounding areas). In addition, clinicians should attempt to reach the patient by phone to discuss their elopement and any additional care issues or concerns. Documentation of these attempts or any additional conversation is critical in mitigating legal risks [3,4].

Conclusion

Discharge instructions are a very important part of the emergency department care process and record. It is essential to ensure each patient has a complete understanding of their instructions in order to promote care compliance and improve transitions in care. Verbal instructions remain more effective than written instructions, but both are needed and a multimodal approach to relaying information is preferable to a single modality. Be explicit, keep it simple, and have the patients repeat back instructions to ensure understanding. These simple steps will improve patient outcomes and compliance, and help clinicians avoid medical and legal pitfalls.

Authors

Dominique GELMANN

Dominique Gelmann is an Emergency Medicine resident at Wake Forest University. Her interests include patient-physician communication and health literacy. During medical school she completed a one-year research and leadership fellowship investigating health literacy as a social determinant of health, and helped author an institutional white paper with actionable strategies for improving health literacy education. She has given several lectures on the topic to various audiences, and developed a curriculum on health literacy and best-practice patient-provider communication principles for a free student-run health clinic. She looks forward to continuing strengthening her passion for this work throughout her career.

Bret NICKS

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2018 version of this topic – https://iem-student.org/discharge-communications/

References

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Taylor DM, Cameron PA. Discharge instructions for emergency department patients: what should we provide? J Acad Emerg Med. 2000; 17:86-90.
Zeng-Treitler Q, Kim H, Hunder M. Improving Patient Comprehension and Recall of Discharge Instructions by Supplementing Free Texts with Pictographs. AMIA Annu Sympo Proc 2008:849-853.
Choudhry AJ, Baghdadi YM, et al. Readability of discharge summaries: with what level of information are we dismissing our patients? Am J Surg. 2016 Mar; 211(3): 631–636. PMID: 26794665.
Al-Harthy N, Sudersanadas KM, Wagie AE, et al. Efficacy of patient discharge instructions: A pointer toward caregiver friendly communication methods from pediatric emergency personnel. J Family Community Med. 2016 Sep-Dec; 23(3): 155–160. PMID: 27625582.
Gutman CK, Cousins L, Gritton J, et al. Professional interpreter use and discharge communication in the pediatric emergency department. Acad Pediatr. 2018;18(8):935–943. PMID: 30048713.
Oller C. Discharge Moment of Safety. Available at: https://www.youtube.com/watch?v=xuLjBWkfomE Accessed January 30, 2016.
Pham JC, Ijagbemi M. Improving the ED Discharge Process. ACEP. Available at: http://www.acep.org/content.aspx?id=90940 Accessed January 15, 2016.
DeSai C, Janowiak K, Secheli B, et al. Empowering patients: simplifying discharge instructions. BMJ Open Qual. 2021 Sep; 10(3).
Levy F, Mareiniss DP, Lacovelli C. The Importance of a Proper Against-Medical-Advice (AMA) Discharge. How Signing Out AMA May Create Significant Liability Protection for Providers. J Emerg Med. 2012;43(3):516-520.
Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51:899-902.

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Communication and Interpersonal Interactions (2023)

May 1, 2023October 11, 2024 ~ iEM Education Project Team ~ Leave a comment

by Nicholas Macklin, Bret Nicks

Introduction

Emergency Medicine and the situations within the department can present a stressful, rapidly changing environment where it may feel as though there is too little time for effective patient communication, patient-centered care, or the opportunity to establish an appropriate provider-patient relationship. It is also an environment unlike any other in medicine, where a unique team of individuals facing varying degrees of chaos with limited available information work together to address the medical conditions of those presenting to the department. Few would recommend entering such an environment in the absence of an established care process and means of clearly communicating. Understanding that preconceived notions and prejudices must remain at the door from the moment you walk in to the emergency department (ED) sets the tone for the entire shift.

It is no surprise that high-performing emergency departments have high-performing, well-communicating teams. Clearly defining and communicating why we are there and how we care for patients for every member of the team sets the tone for every interpersonal interaction. This is true not just with our patient-provider interaction, but our interaction with nursing, ancillary, and consultant staff [1]. Establishing a team mentality and acknowledging the value of the contributions of our colleagues and staff to the ED is essential to practicing high-quality, safe emergency medical care.

The skills that non-physician health professionals bring to the team can help us to better understand our patient’s expectations and needs – facilitating the best care that can be offered in the ED [2].

Essentials of Communication

The approach to provide high-quality patient care in the ED starts with recognizing the inherently mismatched perspective between the patient and physician [3]. It is essential to recognize the patient-physician relationship starts with a large power imbalance. Attempts should be made to normalize or reduce this power imbalance, so as to empower the patient and their families to openly discuss their medical concerns and assist with making informed decisions for their care. Acknowledge the wait or process they have already endured prior to seeing you. Thank the patient (and family) for coming to the ED and allowing you to address their medical concerns. Also, take the time to introduce yourself to everyone in the room with the patient and find out who they are in relation to the patient as this can help establish rapport with the patient and those around them [4-6]. When introducing yourself and other members of the care team, be sure to clearly define roles in terms the patient can understand. This is of particular importance when working with trainees. Patients tend to have a poor understanding of medical education and training, but want to know the role and level of training of their providers [7].

While many believe the environment of care is the greatest limiting factor to quality communication, literature would suggest otherwise. Establishing a positive patient-provider relationship is essential. Recognizing that you may not be able to solve the patient’s condition or chronic illness, but using effective communication skills and providing a positive patient experience will assuage many patient fears [8]. Keep in mind, in general, patients remember < 10% of the content (what was actually said), 38% of how you say it (verbal liking), and 55% of how you look saying it (body language) [3]. Effective provider communicators routinely employ these 5 Steps:

1. Be Genuine

Most people are able to quickly intuit when someone is not being forthcoming. Although we are often balancing competing interests for our time and attention, make every effort to ensure that you are taking a genuine, transparent approach to both receiving and providing information. An effective means of achieving this is to take an earnest interest in your patient. This often requires putting aside personal fatigue and bias. If you can entrain a genuine interest in a patient’s concerns, your interaction will be more natural and the patient will be more likely to trust you.

2. Be Present

As emergency providers, we are interrupted more than perhaps any other specialty. However, for the brief time that we are engaged with the patient or their family, be fully attentive. If there is a planned interruption upcoming, make it known prior to starting a discussion. Be focused on them and the conversation – and value what they have to share. At the end of your encounter, briefly summarizing what the patient has told you can help to reassure the patient that you were listening and also give them the chance to clarify discrepancies.

3. Ask Questions

To effectively communicate, one must listen more than they talk. After introducing yourself, inquire about the patient’s medical concern Give them 60 seconds of uninterrupted time. Most patients provide unique insights that may otherwise not have been obtained. Then begin with the specific questions needed to further differentiate the care concern. By asking questions and allowing for answers, you make it about them and give them an avenue to share with you what they are most concerned about and allow you to address those concerns.

4. Build Trust

Given the nature of the patient-provider relationship in emergency medicine, building trust is essential but often difficult. Building trust is like building a fire, it starts with the initial contact and builds with each interaction – and is based on culturally acceptable interactions (e.g. handshake, affirming node, hand-on-shoulder, engaging posture, etc.) [4].

5. Communicate Directly

By the end of the initial encounter, ensure that you have established a clear plan of care, what the patient can expect, how long it may take, and when you will return to reassess or provide additional information. Doing this also allows the patient to be more involved in their care and ask further questions regarding their workup and treatment plan. Additionally, helping the patient to understand what they can expect while in the department can help to alleviate fear associated with unannounced tests or imaging studies, especially when these tests may require them to be temporarily taken out of the department (e.g. a trip to the CT scanner). While patients generally trust physicians to make decisions about advanced imaging such as CT, they still want to be included in the decision-making process [9].

Empathy

When considering this, it is essential to understand that much of this relates to empathy – the ability to understand and share another person’s experiences and emotions. It is often said, try to understand the patient’s agenda: ‘Help me understand what brought you in today’, ‘help me understand what I can do for you’, ‘tell me more’. This will help to normalize the patient’s situation and gain unique insights into their care concerns. There are 4 easy steps to improve reflective listening and perceived empathy in the ED:

Echo: Repeat what the patient says; this gives the message that you heard the patient.
Paraphrase: Rephrase what the patient says; this gives the message that you understand the patient.
Identify the feeling: Say, for example ‘you seem frustrated’, ‘worried’, ‘upset’ as this produces trust.
Validation: Validate the patient’s feelings verbally such as ‘I can see why you feel that way’.

It is human nature that empathy will be more intuitive for some, but all can practice empathic communication skills to better identify the needs of your patient. By implementing the above approach, physicians can improve their ability to elicit concerns that a patient may not have been able to otherwise articulate. Using a predefined approach may feel mechanical or forced, but standardized communication interventions have been shown to positively impact patients’ perception of the encounter [10].

For those seeking additional structure to practice, there is also a great online module and mnemonic for Empathetic Listening skills development [11]. The RELATE mnemonic is:

Reassure – share your qualifications and experience.
Explain – describe in clear concise language what the patient can expect.
Listen – not just hear and encourage the patient to ask questions.
Answer – summarize what they have said and confirm their understanding.
Take Action – discuss and define the care steps (and what to expect)
Express Appreciation – thank the patient for allowing you to care for them.

The Approach

As with many things, effective communication is the glue that helps establish connections to others and improve teamwork, decision-making, and problem solving. It facilitates the ability to convey even negative or difficult messages without creating conflict or distrust. Recognizing this, the right approach for successful patient communication is essential. In addition to understanding the above 5 steps of effective communication, the approach to this must also be refined by each individual and adjusted for the unique circumstances of each patient encounter. For a moment, consider seeing the situation from the patient’s perspective regarding your approach and set the tone with these 3 starting points.

The 3 Starting Points:

1) Approach and Appearance:

Sit down next to the patient
Maintain an open posture (avoid crossing your arms)
Maintain eye contact appropriate to local cultural norms
Use non-verbal cues to acknowledge what is being said (e.g. nodding, smiling, using eyes to show interest)
Dress appropriately

2) How to speak:

Speak slowly and clearly (given the constraints of the ED)
Use a low, calm tone in your voice
Be mindful that patients will sense any frustration or impatience in your tone

3) What to say:

Introduce yourself in a culturally appropriate manner
Use the patient’s last name, particularly if introducing yourself by your last name (this helps to minimize power imbalance)
Acknowledge everyone in the room and clarify their relationship to the patient
Adjust medical wording based on patient’s medical literacy

In addition to understanding the 5 essentials of communication and setting the tone with the initial care approach, it is important to understand some of the most common reasons communication is successful and fails in the Emergency Department. While a single approach framework doesn’t always fit every situation, there are some essential Do’s and Don’ts that must also be considered.

Do's

Let the patient tell their story [9].
Establish the patient’s goals of the encounter.
Elicit any feared conditions or diagnoses, as well as any desired therapeutics or diagnostics (It is generally better to address these pre-existing desires early in the encounter).
Provide the patient with information regarding what will happen during their stay. This puts patients more at ease and improves satisfaction [6].
Provide honest estimates of expected wait times. Some experts suggest overestimating the time for results and consultant services (Disney Technique).
Explain reasons for delays, and readily apologize for
Map out the next steps in the process in the ED after your history and physical.

Don'ts

Fold your arms over your chest as this displays an aggressive posture
Ask why the patient did not come in earlier
Say ‘I guess’
Repeatedly ask ‘why’
Use the words ‘never’ or ‘always’
Ignore elephants in the room
Dismiss their concerns without explanation

The Difficult Patient

When engaging difficult patients in the emergency department, understanding the situation and the drivers for the patient may help to better navigate the communication challenges that are present. A difficult patient encounter in the emergency department can often be frustrating for both the physician and the patient. These patients often present with chronic medical issues that are exacerbated by social disparities [13-14]. These are just a few examples of types of patients that one may encounter in the emergency department:

Angry Patient

Don’t ignore that a patient may be angry or upset. Their frustration is often related to delays, expectations, or care concerns. Try to explore this by asking neutral and non-confrontational questions. If possible, identify and acknowledge their dominant underlying emotion. Statements as simple as “It seems like you’re frustrated” or “I suspect we’re not meeting your expectations today” can lead to meaningful dialogue when a patient feels acknowledged. A simple but genuine apology can completely change the end of an encounter, such as apologizing for a long wait or for not being able to do more in our limited capacity in the ED.

Manipulative Patient

While these patients may clearly have secondary gain, their medical complaints are often still legitimate. Approach these patients with an open mind and differential, but be prepared to say “no” to requests that are not clinically indicated. When in doubt, give patients the benefit of the doubt rather than prematurely dismissing a legitimate need.

Frequent Fliers / High Utilizers

High recidivism may be frustrating, but it is important to understand that there may be an underlying reason for frequent ED visits. Socioeconomic factors resulting in poor access to care are common reasons. Maintaining familiarity with available resources (e.g. social workers, clinical support nursing) can make a tremendous difference.

Combative, Agitated, or Intoxicated Patient

It is most important to keep both the patient and the staff (including yourself) safe. Redirecting the patient and emphasizing the importance of caring for them medically may help to calm the situation. It is remarkably easy to inadvertently escalate an agitated patient’s behavior. Maintain firm boundaries while maintaining a calm, reserved demeanor. Psychopharmacological intervention may be necessary at times.

In difficult encounters, there are times when an impasse is reached and it is clear that the goals of the patient will not be met. Even if your care is medically appropriate and effort has been made to respect the patient’s autonomy, these scenarios are sometimes unavoidable. In such situations, it is important to emphasize that you are acting in what you feel to be the patient’s best interest. If appropriate, apologize for their frustrations or any misunderstanding. Give the patient time to express themselves, but also practice identifying when it is time to give the patient space.

For a deeper dive into effective patient communication related to managing difficult patients, listen to Episode 51: Effective Patient Communication – Managing Difficult Patients by Anton Helman. http://emergencymedicinecases.com/episode-51-effective-patient-communication-managing-difficult-patients/

The Culturally-Discordant Encounter

The emergency department is a nexus not just for all members of a community, but for anyone in the area needing assistance. Physicians in the emergency department can expect to encounter a diverse patient population, regardless of physical location. Healthcare professionals will therefore invariably encounter those of cultural backgrounds that differ from their own. These cultural backgrounds include race, religion, and nationality, among many others. While an entire chapter could be dedicated to communication in this setting, here are a few key points to form a foundation.

1. Minimize any language barrier

Making efforts to minimize a language barrier is often easier said than done. For any encounter in which the primary languages of the patient and physician are not the same, an interpreter should be offered whenever possible. It can be immensely tempting to over-estimate a patient’s fluency in a language to avoid having to use a language interpreter. However, it is well-demonstrated that language barriers are associated with a variety of negative impacts on patient care including decreased diagnostic confidence, increased ancillary testing, decreased patient satisfaction, and delays in analgesia [15-17]. Family members should not be used as interpreters whenever possible. They can have their own agendas and biases, as well as variable health literacy.

2. Be mindful of one’s own biases

It is an unfortunate truth that implicit biases exist in every person. Healthcare professionals should be mindful of the poorer communication and health outcomes minority races tend to receive [18,19]. Employing a genuine, empathic style of communication is an excellent foundation for mitigating one’s biases.

3. Familiarize yourself with differing cultural norms

There are far too many cultural norms for any one person to know. If there are specific communities of differing cultural backgrounds in your area, make an effort to learn differences in verbal and non-verbal cues. If unsure, it is generally prudent to “be yourself” and exhibit calm, deliberate mannerisms.

The Handoff

Communication between providers and specifically patient care transitions present one of the well-known challenges in patient care and errors in care management. This handoff communication, often perceived as the ‘gray zone’, has been characterized by ambiguity about patient medical condition, treatment and disposition [20]. Communication errors, particularly related to patient hand-offs, account for nearly 35% of ED related care errors. Establishing a standardized process to ensure quality and clarity of transitions in care are essential. One such example is the I-CAN format, which is specifically focused on the ED patient population.

I - Introduction

Briefly describe what brought the patient into the emergency department today. For example: Patient is a 53 yo male with past medical history of COPD who presents today with productive cough, wheezing and shortness of breath.

C - Critical Content & Interventions Performed

Relate information that helps the receiving provider understand the ED course. For example: On initial evaluation the patient was unable to speak in full sentences and O2 saturation was 88% on room air. We started him on NIPPV and provided nebulizer treatments and IV steroids.

A - Active Issues

Provide an overview of the patient’s current condition. For example: Patient improved after an hour of NIPPV and was transitioned to high flow nasal cannula with O2 saturation at 93%. We are currently attempting to wean O2 requirements as tolerated.

N - Next Steps & Anticipated Disposition

Describe to the receiving provider what will need to be followed up and anticipated disposition of the patient. For example: The patient will need to be admitted for a COPD exacerbation with a new O2 requirement. He can go to a floor bed if he remains stable on nasal cannula.

While many examples for a unified handoff exist, identifying a defined approach and establishing the expectation for routine use, especially when integrated into the electronic health record at transitions of care, ensure improvement with patient care, quality and throughput [20,21]. If the patient and family are involved with this handoff, not only will they understand care expectations, but better understand issues with delays, next steps, and care updates.

Conclusion

Most agree that providing patient care in the ED poses many challenges. The situations within which we work can present a stressful, rapid environment where it may feel as though we have too little time for effective patient communication, patient-centered care or opportunity to establish a great patient experience. However, it is also evident that improved communication between the care team and patients not only improves the care experience but also improves patient care outcomes. Quality communication improves patient outcomes, compliance and satisfaction – not to mention job and team satisfaction.

While many techniques exist to improve ED communication, establishing a culture in the ED to habitually adapt these practices is essential. The ED is indeed an environment unlike any other in medicine, where a unique team of individuals work in varying degrees of chaos with limited available information working together to address the medical conditions of those presenting to the department. Doing so with effective communication can make a difference.

Authors

Nicholas MACKLIN

Nicholas Mackin, MD is a Clinical Assistant Professor in the Department of Emergency Medicine at Wake Forest Baptist Medical Center in Winston Salem, NC, USA.

Bret NICKS

Listen to the chapter

Cite This Article

Please replace “iEM Education Project Team” below with the author(s) surname and initials.

[cite]

2018 version of this topic – https://iem-student.org/communication-and-interpersonal-interactions/

References

Gluyas H. Effective communication and teamwork promotes patient safety. Nurs Stand. 2015 Aug 5;29(49):50-7.
Klauer K, Engel KG. Patient-centered Care. Emergency Medicine Clinical Essentials, 2^nd Ed. Elsevier, 2013; 1784-89.
Helman A. Effective Patient Communication. Available at: http://emergencymedicinecases.com/episode-49-patient-centered-care/ Accessed December 18, 2015.
Chan EM, Wallner C, Swoboda TK, et al. Assessing Interpersonal and Communication Skills in Emergency Medicine. Acad Emerg Med 2012; 19:1390-1402.
Cinar O, Ak, M, Sutcigil L, et al. Communication skills training for emergency medicine residents. Eur J Emerg Med. 2012; 19:9-13.
Hobgood CD, Riviello RJ, Jouriles N, Hamilton G. Assessment of communication and interpersonal skills competencies. Acad Emerg Med. Nov 2002; 9(11):1257-69.
Hemphill RR, Santen SA, Rountree CB, Szmit AR. Acad Emerg Med. 1999 Apr;6(4):339-44.
Mole TB, Begum H, Cooper-Moss N, et al. Limits of ‘patient-centeredness’: valuing contextually specific communication patterns. Med Educ. 2016 Mar; 50(3):359-69.
Caoili EM, Cohan RH, Ellis JH, et al. Medical Decision Making Regarding Computed Tomographic Radiation Dose and Associated Risk: The Patient’s Perspective. Arch Intern Med. 2009;169(11):1069-1081.
Custer A, Rein L, Nguyen D, et al. Development of a real-time physician–patient communication data collection tool. BMJ open quality. 2019 Nov 1;8(4):e000599.
The History of Empathy – SMACC. Available at: http://broomedocs.com/2014/09/the-history-of-empathy-from-smacc-gold/ Accessed February 20, 2016.
Roscoe LA, Eisenberg EM, Forde C. The Role of Patient Stories in Emergency Medicine Triage. Health Commun. 2016 Feb 16:1-10.
Hull SK, Broquet K. How to manage the difficult patient. Family Practice Management. 2007 June: 30-34.
Dudzinski DM, Timberlake D. Difficult Patient Encounters. Ethics in Medicine. Available at: https://depts.washington.edu/bioethx/topics/diff_pt.html Accessed February 20, 2016.
Garra G, Albino H, Chapman H, Singer AJ, Thode Jr HC. The impact of communication barriers on diagnostic confidence and ancillary testing in the emergency department. The Journal of emergency medicine. 2010 Jun 1;38(5):681-5.
Gaba M, Vazquez H, Homel P, Likourezos A, See F, Thompson J, Rizkalla C. Language barriers and timely analgesia for long bone fractures in a pediatric emergency department. Western Journal of Emergency Medicine. 2021 Mar;22(2):225.
Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. Impact of language barriers on patient satisfaction in an emergency department. Journal of general internal medicine. 1999 Feb;14:82-7.
Shen MJ, Peterson EB, Costas-Muñiz R, Hernandez MH, Jewell ST, Matsoukas K, Bylund CL. The effects of race and racial concordance on patient-physician communication: a systematic review of the literature. Journal of racial and ethnic health disparities. 2018 Feb;5:117-40.
Hagiwara N, Slatcher RB, Eggly S, Penner LA. Physician racial bias and word use during racially discordant medical interactions. Health communication. 2017 Apr 3;32(4):401-8.
Akper J, Mallak LA, Gibson SC. Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007 Oct;14(10):884-94.
Rourke L, Amin A, Boyington C, et al. Improving residents’ handovers through just-in-time training for structured communication. BMJ Qual Improv Rep. 2016 Feb 8;5(1).

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Approach to the trauma patient – ABCDE of trauma care

January 19, 2022February 19, 2022 ~ Maryam Bagherzadeh, Canada ~ Leave a comment

Case

Jane Doe, 22-year-old female, was in a major car crash and is approaching the trauma bay via an ambulance. You are aware that the patient’s condition is critical, so you do a quick run-through in your head about the approach that you will have to care for them once they arrive to your emergency department. What should your approach to a trauma patient be?

The ABCDE of Trauma Care

The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is a clinically proven approach to any critically ill patient that needs emergent care and treatment. It has been proven to improve patient outcomes, optimize team performance and save time when patients are in life-threatening conditions [1]. This approach is applicable to all patients (both adults and children), regardless of their underlying condition. However, the ABCDE approach is not applicable to patients who are in cardiac arrest, in which case the cardiopulmonary resuscitation guidelines should be used [2].

With the ABCDE approach, initial assessment and treatment are performed simultaneously. Once the entire survey is completed, reassessment should be conducted until the patient is stable enough for the care team to be able to move on to the secondary survey and look for a definitive diagnosis.

A - Airway

First, the care team should assess if the patient’s airway is patent. If the patient responds to the team in a normal voice, then that is a good sign that the airway is intact. It is important to note that airway obstruction can be complete or partial, and can be caused by upper airway obstruction or reduced level of consciousness.

Signs of complete airway obstruction are lack of respiration despite great effort. Signs of partial airway obstruction include:
– Changes in the patient’s voice
– Snoring or gurgling
– Stridor (noisy breathing)
– Increased breathing effort

Assess the patient’s airway by looking for rocking chest wall motion and any signs of maxillofacial trauma or laryngeal injury. Perform the head-tilt and chin-lift maneuver to open the airway (note that caution should be conducted in patients with C-spine injury). If there is anything that is noticeably obstructing the airway, suction or remove it. If possible, remove foreign bodies that are causing airway obstruction. Provide high-flow oxygen to the critically ill patient and perform definitive airway if needed [1].

B – Breathing

Generally, airway and breathing are examined simultaneously. Determine if breathing is intact by assessing the respiratory rate, inspecting the chest wall movement for symmetry, depth, and respiratory pattern. Additionally, assess for tracheal deviation and use of respiratory muscles. Percuss the chest for dullness or resonance, auscultate for breath sounds and apply a pulse oximeter [1].

Injuries that impact breathing should be immediately recognized, and life-threatening injuries should be addressed and managed [3]. For example, tension pneumothorax must be promptly relieved by needle thoracocentesis, bronchospasms should be managed with inhalation and assisted ventilation should be considered if breathing continues to be insufficient [1].

C – Circulation

Conditions that threaten the patient’s circulation and can be fatal include shock, hypertensive crises, vascular emergencies such as aortic dissection and aortic aneurisms. These conditions should be immediately identified and managed [1].

Circulation can be assessed by looking at the general appearance of the patient, including signs of cyanosis, pallor, flushing and diaphoresis. Assess for any obvious signs of hemorrhage, blood loss and level of consciousness. Additionally, capillary refill time and pulse rate should be assessed. Auscultate the chest for heart sounds, and blood pressure measurement and electrocardiography should be performed as soon as possible [1].

Additionally, assess for signs of hypovolemia and shock. If these are identified, obtain an intravenous access and infuse saline to restore circulating volume [1]. If there are life-threatening conditions that are compromising the patient’s circulation, promptly identify and treat them as needed. For example, tension pneumothorax should be immediately treated with needle decompression and cardiac tamponade can be relived with pericardiocentesis.

D - Disability

The main disability in the primary survey to be assessed for is the brain. Abnormal neurological status can be caused by primary brain injury or systemic conditions that effect brain perfusion, such as shock, hypoxia, intoxication etc. Assess the level of consciousness by using the Glasgow Coma Scale [4], look for pupillary response and limb movement.

The best way to prevent injury to the brain is to maintain adequate airway, breathing and circulation. Glucose levels can be assessed at bedside for decreased level of consciousness due to low blood glucose levels, and corrected with oral or infused glucose [1].

E – Exposure

The exposure portion of the ABCDE approach involves assessment of the whole-body to avoid any signs of missing injuries. During this part of the management, undress the patient fully and examine the back for any signs of C-spine precautions. Additionally, check for clues for any signs of underlying conditions, such as:

Signs of trauma (i.e. burns, gunshot wounds, stab wounds)
Rashes
Causes of sepsis (i.e. infected wounds, gangrene)
Toxins and drugs (i.e. needle track marks, chemicals, patches)
Other wounds such as bite marks, insect bites, embedded ticks
Iatrogenic causes (i.e. catheters, tubes, implants, surgical sites and scars)

Concluding Remarks

The ABCDE approach to the critically ill patient is a strong and proven clinical tool for initial assessment and treatment of patients in medical emergencies. Widespread knowledge of this skill is critical for healthcare workers and any team providing emergent care to trauma patients.

*Note that this is a general approach to the trauma patient. Always consult your care team for adequate management of trauma patients and resort to reliable resources for more information on the ABCDE approach.

References and Further Reading

Thim, T., Krarup, N. H. V., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International journal of general medicine, 5, 117.
Koster, R. W., Baubin, M. A., Bossaert, L. L., Caballero, A., Cassan, P., Castrén, M., … & Sandroni, C. (2010). European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation, 81(10), 1277-1292.
Subcommittee, A. T. L. S., & International ATLS Working Group. (2013). Advanced trauma life support (ATLS®): the ninth edition. The journal of trauma and acute care surgery, 74(5), 1363-1366.
Sternbach, G. L. (2000). The Glasgow coma scale. The Journal of emergency medicine, 19(1), 67-71.

[cite]

From Missed Hemodialysis to Multiple Arrhythmias

November 2, 2020October 23, 2020 ~ Gayatri Lekshmi Madhavan, India ~ 2 Comments

Case Presentation

A 78-year-old male, known case of Chronic Kidney Disease on maintenance hemodialysis, presented to the Emergency Department with dizziness and lethargy complaints about 2 days. He had missed his last hemodialysis session due to personal reasons. We could not elicit any further history details as was significantly dyspneic (no bystanders with him at the time of presentation). Hence, the patient was received in Bay 1 for immediate resuscitative measures. The patient was afebrile, conscious, and well oriented, but unable to communicate because of severe dyspnea.

Vitals

HR – 142 beats/min
BP – not recordable
RR – 36 breaths/min
SpO2 – poor tracing, intermittently showed 98% on room air (15 LO2 via Non Rebreathing Mask was initiated nevertheless)

ECG

He was immediately connected to a defibrillator in anticipation of possible synchronized cardioversion. Simultaneously, the cause of the possible rhythm was being evaluated for and a thorough examination was carried out. On examination, his lung fields were clear. His left arm AV Fistula had a feeble thrill on palpation.

In suspicion of hyperkalemia as the cause of VT, patient was immediately started on potassium reduction measures while the point of care ABG report was awaited. He was treated with salbutamol nebulization 10mg, sodium bicarbonate 50 ml IV and 10% calcium gluconate 10ml IV. In view of hemodynamic instability, he was also started on intravenous noradrenaline infusion.

ABG Findings

pH – 7.010, pCO2 – 20.8 mmHg, pO2 – 125 mmHg, HCO3 – 7 mmol/L, Na – 126 mmol/L, K – 9.6 mmol/L

As hyperkalemia was confirmed, the patient was also given 200 ml of 25% dextrose with 12 units of Rapid-acting insulin IV. With the above measures, the patient’s cardiac rhythm came to a sine wave pattern.

He was later taken up for emergency hemodialysis (HD) – Sustained Low Efficacy Dialysis (SLED) in the ICU, using a low potassium dialysate. Since his AV fistula was non-functioning, HD was done after placement of a femoral dialysis catheter. 2 hours into HD, the patient’s cardiac monitor showed a normal sinus rhythm. His hemodynamic status significantly improved. Noradrenaline infusion was gradually tapered and stopped by the end of the HD session, and repeat blood gas analysis and serum electrolytes showed improvement of all parameters.

The patient was discharged 2 days later, after another session of hemodialysis (through AV fistula) and a detailed cardiology evaluation (ECHO – LVH, normal EF).

For the Inquisitive Minds

The patient underwent a detailed POCUS evaluation, both in the ER and ICU. What findings do you expect to find on the RUSH examination for this patient?
His previous ECHO report (done 1 month ago) mentioned left ventricular hypertrophy and normal ejection fraction. So what would be the reason behind the POCUS findings? Is it reversible?
Why was the AV fistula non-functioning at the time of presentation? When would it have started to function again?
Despite not having hypoxia, this patient was given supplemental oxygen. Did he really require it, and if so, what was the rationale?
What was the necessity for carrying out SLED for this patient?
Why was this patient not immediately cardioverted in the ER?
If this patient had gone into cardiac arrest, what drugs would you have given for management of hyperkalemia?
How differently would you have managed this patient?

Please give your answers and comments into "leave a reply" area below.

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The Rural Paradox

September 2, 2020August 6, 2020 ~ Carmina Shrestha, Nepal ~ Leave a comment

While trying to refrain from a complainer’s mindset, we often ignore discussing problems and hence seeking solutions.

Carmina Shrestha Tweet

The problem of having less time has existed from the day time and consciousness intersected. There are 24 hours in a day despite most of us wishing for more. I have been many things for many of those 24 hours: a student, an intern, a daughter, a friend, and a doctor. Most of the time, I’d be playing some combination of those roles. While an avid supporter of the make-time mentality, I have struggled with what one might call “Rural doctors paradox”. Simply put, the paradox is: there are supposedly fewer cases, and less severe cases in the rural, so few doctors are posted there which dramatically decreases doctor to patient ratio and has its multi-facet consequences.

What do you imagine when I say a rural doctor? How many patients a day does she look after? When does she wake up? How does her day go by? What does she reflect on while lying on the bed at the end of the day?

Carmina Shrestha Tweet

Not falling victim to the narrative fallacy, I would like to break this complex story into digestible chunks. Today I present you with challenges I as a rural doctor running a 24-hour emergency and a PHC can recall.

Beans again!

At the surface, it would seem like my mom’s lifetime of an attempt at hard-wiring my brain with negotiation skills failed when I agreed to buy potatoes at the offered price. The reason wasn’t my inattentiveness during those joyous negotiation classes I received, rather a phone call I used to dread the moment I stepped out of the PHC premise. “An unconscious middle-aged male is brought to the ER…”, said my health assistant. I was out buying vegetables for the week. I had to rush to the ER; 15 minutes of a run, tempo, hitchhiking, or teleportation.

Do hell with potatoes; I’ll make beans for dinner today, again!

Carmina Shrestha Tweet

Good but far.

“The view is serene, climate adequately cold and it is just 35 minutes away from here”. The picnic spot pitched by an office staff really stood out. Everyone was excited before we proceeded to choose, by lottery, the unfortunate souls who’d be in duty on the day. I was lucky enough to not have to stay, but that meant we would have to comply with the 30 minutes rule. Being 30 minutes far from the PHC would provoke anxiety of not reaching the PHC on time if need be. The consensus was it was not worth the risk.

Not me! The USG doctor!

“Why would the doctor make us wait for so long?”, said a patient to no one in particular. She has been waiting for her obstetric USG for an hour or so. After taking a quick shower to get rid of the stench and bacteria I accumulated from doing an autopsy on the days-old body, I rushed down to the USG room. “I hope no serious case arrives at the ER today!”, I find myself thinking. That day, while going to my bed, I reflected that the patient wasn’t mad at me for being late. Not the whole of me anyways. The me that was in the autopsy, she is fine. The patient was angry at the USG doctor. It just so happens to be me too.

Just another rainy day

Brinjals, Potatoes, Rice, and some medication: that is a typical to-get list of a villager who walks for quite some time to get to the marketplace on Thursdays. “My child often gets feverish! It was a market-day so I could not bring him with me”, says the 116th patient on a typical Thursday.

There are days when we literally wait for patients while enjoying the bright sun and delicious peanuts too. Busy-ness has a predictable spectrum in Beltar.

Carmina Shrestha Tweet

Like any other predictable spectrum, there are curve-balls once in a while. Those are the days that I remember the most when I look back.

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Emergency Department Crowding: A conceptual model

June 19, 2020June 12, 2020 ~ Temesgen Beyene, Ethiopia ~ Leave a comment

Overcrowding is a serious problem in healthcare systems all around the world. In particular, Emergency Departments, which, by definition, deal with acute and unscheduled patients, are more susceptible to overcrowding. Even the parts of the world with developed hospital systems suffer from ED overcrowding, the burden is heavier in the developing world. Emergency department crowding is a significant barrier that prevents patients from receiving adequate and timely care.

Researchers of this field and policymakers had recognized the importance of the problem for ages, but COVID-19 pandemic highlighted it once again. Asplin et al’s conceptual model, published in Annals of Emergency Medicine in August 2003, continues to be relevant today and helps all stakeholders of emergency care -researchers, policymakers and administrators alike- to come up with sounding solutions. According to this conceptual model (See figure below) causes of ED overcrowding is divided into 3 independent components, namely, input causes, throughput causes and output causes.

At different times, multiple components occur to some extent in all acute care centres. This conceptual model provides an overview of overcrowding causes so that administrators may review what’s failing and develop more efficient emergency department operations and policies. Subsequently, it will help to reduce ED crowding. Also, learning how ED, as a workplace, works on an organizational level has the potential to increase medical graduates’ interest in research and policymaking, thus, feedback on system design from diverse stakeholders.

Reference

Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA Jr. A conceptual model of emergency department crowding. Ann Emerg Med. 2003;42(2):173‐180. doi:10.1067/mem.2003.302

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Acute Management of Supraventricular Tachycardias

January 10, 2020January 10, 2020 ~ Elif Dilek Cakal, Turkey ~ Leave a comment

The term “supraventricular tachycardia (SVT)” expresses all kinds of rhythms that meet two criteria: Firstly, the atrial rate must be faster than 100 beats per minute at rest. Secondly, the mechanism must involve tissue from the His bundle or above. Mechanism-wise, atrial fibrillation resembles SVTs. However, supraventricular tachycardia traditionally represents tachycardias apart from ventricular tachycardias (VTs) and atrial fibrillation (1,2).

Supraventricular tachycardias are frequent in the ED!

The SVT prevalence is 2.25 per 1000 persons. Women and adults older than 65 years have a higher risk of developing SVT! SVT-related symptoms include palpitations, fatigue, lightheadedness, chest discomfort, dyspnea, and altered consciousness.

How to manage supraventricular tachycardia?

In clinical practice, SVTs are likely to present as narrow regular complex tachycardias. Concomitant abduction abnormalities may cause SVTs to manifest as wide complex tachycardias or irregular rhythms. However, 80% of wide complex tachycardias are VTs. Most importantly, SVT drugs may be harmful to patients with VTs. Therefore, wide complex tachycardias should be treated as VT until proven otherwise (1,2).

The chart below summarizes acute management of regular narrow complex tachycardias:

References and Further Reading

Brugada, J., Katritsis, D. G., Arbelo, E., Arribas, F., Bax, J. J., Blomström-Lundqvist, C., … & Gomez-Doblas, J. J. (2019). 2019 ESC Guidelines for the management of patients with supraventricular tachycardia: the Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). European Heart Journal, 00, 1-66.
Page, R. L., Joglar, J. A., Caldwell, M. A., Calkins, H., Conti, J. B., Deal, B. J., … & Indik, J. H. (2016). 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Journal of the American College of Cardiology, 67(13), e27-e115.

Epistaxis on a Flight

December 27, 2019December 24, 2019 ~ Sumaiya Hafiz, UAE ~ Leave a comment

A couple of days ago, a friend told me about an incident that had occurred on a plane where a middle-aged man was found to have epistaxis (bleeding from the nose) midway between a 4-hour flight. Although epistaxis has various degrees of severity and only a small percent are life-threatening, the sight of blood, no matter the amount, is a cause of panic and anxiety for everyone. Hence, the cabin crew was called and helped in managing the patient until the flight landed.

Some of the causes of epistaxis on a flight are dryness in the nose due to changes in cabin pressure and air conditioning. Other causes depend on patients’ previous health problems, which may include medications such as warfarin, bleeding disorders, nose-picking.

As important as it is to learn the emergency management of epistaxis in a hospital setting, often you come across a scenario such as this, in your daily life and its essential to know how to manage it, out of the hospital setting or even in the emergency department, while taking history or waiting to be seen.

The following are a few steps you can take for initial conservative management of epistaxis:

Make sure they are breathing normally and not in any distress, asses their condition and if you think this could be a major emergency, contact the doctor or call for an ambulance
Ask them to bend forward toward their waist while sitting up (to prevent swallowing of blood)
Place cotton wool or tissue into the bleeding part of the nose
Pinch the soft part (alae tightly against the septum) of the nose just above the nostrils for 10-15 minutes
Blowing the nose to expel blood and clots
Additionally, an ice pack can be pressed on the bridge of the nose to stop bleeding

If the following measures fail, further medical management may be advised.

Overview

Epistaxis is acute hemorrhage from the nose, nostrils, nasopharynx, and can be either anterior or posterior, depending on the source of bleeding. It is one of the most common Otolaryngological Emergencies.

Anterior bleeds are the most common, and a large proportion is self-limited. The most common site is ‘Little’s area’ also known as Kiesselbach’s plexus (Anastomosis of three primary vessels occurs in this area: the septal branch of the anterior ethmoidal artery; the lateral nasal branch of the sphenopalatine artery; and the septal branch of the superior labial branch of the facial artery).

FirstAdmiral [CC BY-SA 3.0 de], via Wikimedia Commons

Posterior bleeds are less common and occur from posterolateral branches of the sphenopalatine artery and can result in significant hemorrhage.

Causes of epistaxis

Nose picking, dryness, allergic or viral rhinitis, foreign body, trauma, medications (anticoagulants), platelet disorders, nasal neoplasms, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), aspirin.

Assessment and Management

ABC approach is a standard. Fluid resuscitation in severe cases
History: severity, duration, previous episodes, trauma, medications, family history, infections
Initial conservative management: as mentioned earlier including spraying the nares with oxymetazoline
Examination: mental status, signs of shock, and coagulopathy and examination of the nose
Treatment options: Chemical cautery is usually performed with silver nitrate, Nasal Packing, Nasal Tampons, Gauze Packing, Nasal Balloon Catheters, Tranexamic acid, Thrombogenic foams and gels
Treatment specific to posterior bleeds : Balloon catheter, Foleys catheter, Cotton Packing

References and Further Reading

Alter Harrison. Approach to the adult epistaxis. [December 24th, 2019] from: https://www.uptodate.com/contents/approach-to-the-adult-with-epistaxis

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Death on the Roads

November 1, 2019October 31, 2019 ~ Ibrahim Sarbay, Turkey ~ Leave a comment

Save the date: 17th November 2019!

Why? Because road victims will be remembered that day. Starting from 2005, The World Day of Remembrance for Road Traffic Victims is held on the third Sunday of November each year to remember those who died or were injured from road crashes (1).

Road traffic injuries kill more than 1.35 million people every year and they are the number one cause of death among 15–29-year-olds. There are also over 50 million people who are injured in non-fatal crashes every year. These also cause a real economic burden. Total cost of injuries is as high as 5% of GDP in some low- and middle-income countries and cost 3% of gross domestic product (2). It is also important to note that there has been no reduction in the number of road traffic deaths in any low-income country since 2013.

Emergency care for injury has pivotal importance in improving the post-crash response. “Effective care of the injured requires a series of time-sensitive actions, beginning with the activation of the emergency care system, and continuing with care at the scene, transport, and facility-based emergency care” as outlined in detail in World Health Organization’s (WHO) Post-Crash Response Booklet.

As we know, the majority of deaths after road traffic injuries occur in the first hours following the accident. Interventions performed during these “golden hours” are considered to have the most significant impact on mortality and morbidity. Therefore, having an advanced emergency medical response system in order to make emergency care effective is highly essential for countries.

Various health components are used to assess the development of health systems by country. Where a country is placed in these parameters also shows the level of overall development of that country. WHO states that 93% of the world’s fatalities related to road injuries occur in low-income and middle-income countries, even though these countries have approximately 60% of the world’s vehicles. This statistic shows that road traffic injuries may be considered as one of the “barometer”s to assess the development of a country’s health system. If a country has a high rate of road traffic injuries, that may clearly demonstrate the country has deficiencies of health management as well as infrastructure, education and legal deficiencies.

WHO is monitoring progress on road safety through global status reports. Its’ global status report on road safety 2018 presents information on road safety from 175 countries (3).

We have studied the statistics presented in the report and made two maps (All countries and High-income countries) illustrating the road accident death rate by country (per 100,000 population). You can view these works below (click on images to view full size).