Category: Management

Discharge Communications (2023)

Discharge Communications
~ iEM Education Project Team ~ Leave a comment

by Dominique Gelmann, Bret Nicks

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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

  1. Have the right diagnosis
  2. Time & Action Specific Instructions
    • What to do
    • When to do it
  3. 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
  1. Has the medical provider discussed the findings, diagnosis and plan of care (including medications and follow-up plan)?
  2. Confirm the discharge instructions and prescriptions match the patient identifiers
  3. Review all prescriptions and clarify any changes
  4. Review current vital signs
  5. 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

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

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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Cite This Article

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

Cite this article as: iEM Education Project Team, "Discharge Communications (2023)," in International Emergency Medicine Education Project, May 15, 2023, https://iem-student.org/2023/05/15/discharge-communications-2023/, date accessed: May 28, 2023

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

References

  1. Clarke C, Friedman SM, Shi K, et al. Emergency department discharge instructions comprehension and compliance study. CJEM 2005 Jan;7(1):5-11.
  2. Clark PA, Drain M, Gesell SB, et al. Patient perceptions of quality in discharge instruction. Patient Educ Couns. 2005 Oct;59(1):56-68.
  3. Henry GL, Gupta G. (2013). Medical-Legal Issues in Emergency Medicine. In Adams (Ed.), Emergency Medicine Clinical Essentials, 2nd Ed; 1759-65. Philadelphia, PA: Elsevier.
  4. Siff JE. (2011). Legal Issues in Emergency Medicine. In Tintinalli’s (Ed.), Emergency Medicine, 7th Ed; 2021-31. McGraw-Hill.
  5. Crane JA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med 1997;15:1–7
  6. Engel KG, Buckley BA, Forth VE, et al. Patient Understanding of Emergency Department Discharge Instructions: Where Are Knowledge Deficits Greatest? Acad Emerg Med 2012; 19(9):1035-1044.
  7. Sameuls-Kalow ME, et al. Unmet Needs at the Time of Emergency Department Discharge. Acad Emerg Med. 2015 Dec 18.
  8. Taylor DM, Cameron PA. Discharge instructions for emergency department patients: what should we provide? J Acad Emerg Med. 2000; 17:86-90.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. Oller C. Discharge Moment of Safety. Available at: https://www.youtube.com/watch?v=xuLjBWkfomE Accessed January 30, 2016.
  14. Pham JC, Ijagbemi M. Improving the ED Discharge Process. ACEP. Available at: http://www.acep.org/content.aspx?id=90940 Accessed January 15, 2016.
  15. DeSai C, Janowiak K, Secheli B, et al. Empowering patients: simplifying discharge instructions. BMJ Open Qual. 2021 Sep; 10(3).
  16. 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.
  17. 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

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)

~ iEM Education Project Team ~ Leave a comment

by Nicholas Mackin, Bret Nicks

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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:

  1. Echo: Repeat what the patient says; this gives the message that you heard the patient.
  2. Paraphrase: Rephrase what the patient says; this gives the message that you understand the patient.
  3. Identify the feeling: Say, for example ‘you seem frustrated’, ‘worried’, ‘upset’ as this produces trust.
  4. 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 MACKIN

Nicholas MACKIN

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

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.

Listen to the chapter

Cite This Article

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

Cite this article as: iEM Education Project Team, "Communication and Interpersonal Interactions (2023)," in International Emergency Medicine Education Project, May 1, 2023, https://iem-student.org/2023/05/01/communication-and-interpersonal-interactions-2023/, date accessed: May 28, 2023

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

References

  1. Gluyas H. Effective communication and teamwork promotes patient safety. Nurs Stand. 2015 Aug 5;29(49):50-7.
  2. Klauer K, Engel KG. Patient-centered Care. Emergency Medicine Clinical Essentials, 2nd Ed. Elsevier, 2013; 1784-89.
  3. Helman A. Effective Patient Communication. Available at: http://emergencymedicinecases.com/episode-49-patient-centered-care/  Accessed December 18, 2015.
  4. Chan EM, Wallner C, Swoboda TK, et al. Assessing Interpersonal and Communication Skills in Emergency Medicine. Acad Emerg Med 2012; 19:1390-1402.
  5. Cinar O, Ak, M, Sutcigil L, et al. Communication skills training for emergency medicine residents. Eur J Emerg Med. 2012; 19:9-13.
  6. Hobgood CD, Riviello RJ, Jouriles N, Hamilton G. Assessment of  communication and interpersonal skills competencies. Acad Emerg Med. Nov 2002; 9(11):1257-69.
  7. Hemphill RR, Santen SA, Rountree CB, Szmit AR. Acad Emerg Med. 1999 Apr;6(4):339-44.
  8. 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.
  9. 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.
  10. 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.
  11. The History of Empathy – SMACC. Available at: http://broomedocs.com/2014/09/the-history-of-empathy-from-smacc-gold/ Accessed February 20, 2016.
  12. Roscoe LA, Eisenberg EM, Forde C. The Role of Patient Stories in Emergency Medicine Triage. Health Commun. 2016 Feb 16:1-10.
  13. Hull SK, Broquet K. How  to manage the difficult patient. Family Practice Management. 2007 June: 30-34.
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. 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.
  19. 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.
  20. 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.
  21. 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

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

Approach to the trauma patient – ABCDE of trauma care
~ 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

  1. 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.
  2. 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.
  3. 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.
  4. Sternbach, G. L. (2000). The Glasgow coma scale. The Journal of emergency medicine, 19(1), 67-71.
Cite this article as: Maryam Bagherzadeh, Canada, "Approach to the trauma patient – ABCDE of trauma care," in International Emergency Medicine Education Project, January 19, 2022, https://iem-student.org/2022/01/19/abcde-of-trauma-care/, date accessed: May 28, 2023

From Missed Hemodialysis to Multiple Arrhythmias

From Missed Hemodialysis to Multiple Arrhythmias
~ 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

ECG on presentation
Monomorphic ventricular tachycardia

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. 

after hemodialysis

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

  1. 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?
  2. 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?
  3. Why was the AV fistula non-functioning at the time of presentation? When would it have started to function again?
  4. Despite not having hypoxia, this patient was given supplemental oxygen. Did he really require it, and if so, what was the rationale?
  5. What was the necessity for carrying out SLED for this patient?
  6. Why was this patient not immediately cardioverted in the ER?
  7. If this patient had gone into cardiac arrest, what drugs would you have given for management of hyperkalemia?
  8. How differently would you have managed this patient?

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

Cite this article as: Gayatri Lekshmi Madhavan, India, "From Missed Hemodialysis to Multiple Arrhythmias," in International Emergency Medicine Education Project, November 2, 2020, https://iem-student.org/2020/11/02/missed-hemodialysis/, date accessed: May 28, 2023

The Rural Paradox

rural paradox
~ 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.

Cite this article as: Carmina Shrestha, Nepal, "The Rural Paradox," in International Emergency Medicine Education Project, September 2, 2020, https://iem-student.org/2020/09/02/the-rural-paradox/, date accessed: May 28, 2023

Emergency Department Crowding: A conceptual model

~ 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.

The input-throughput-output conceptual model of ED crowding adapted from Asplin et al. August 2003

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
Cite this article as: Temesgen Beyene, Ethiopia, "Emergency Department Crowding: A conceptual model," in International Emergency Medicine Education Project, June 19, 2020, https://iem-student.org/2020/06/19/emergency-department-crowding-a-conceptual-model/, date accessed: May 28, 2023

Acute Management of Supraventricular Tachycardias

Acute management of SVT
~ 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:

Acute Management of Regular Narrow Tachycardias
SVT ECGs
Sinus Tachycardia
Chest Pain
iEM Top 10

References and Further Reading

  1. 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.
  2. 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

Epistaxis On A Flight
~ 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).

Locus Kiesselbachii Shematic EN 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

Cite this article as: Sumaiya Hafiz, UAE, "Epistaxis on a Flight," in International Emergency Medicine Education Project, December 27, 2019, https://iem-student.org/2019/12/27/epistaxis-on-a-flight/, date accessed: May 28, 2023

Death on the Roads

Death on the Roads
~ 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.

The proportion of population, road traffic deaths, and registered motor vehicles by country income, 2016 (Source: Global Status Report On Road Safety 2018, WHO)

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 has a rather depressing page showing numbers of deaths related to road injuries. (Source: Death on the Roads, WHO, https://extranet.who.int/roadsafety/death-on-the-roads/ )

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).

References and Further Reading

  1. Official website of The World Day of Remembrance, https://worlddayofremembrance.org
  2. WHO. Road traffic injuries – https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries
  3. WHO. Global status report on road safety 2018 – https://www.who.int/violence_injury_prevention/road_safety_status/2018/en/
Cite this article as: Ibrahim Sarbay, Turkey, "Death on the Roads," in International Emergency Medicine Education Project, November 1, 2019, https://iem-student.org/2019/11/01/death-on-the-roads/, date accessed: May 28, 2023

Trauma in Pregnancy

Trauma in pregnancy
~ AlHanouv AlQahtani, KSA ~ Leave a comment

Trauma remains the leading cause of morbidity and mortality in pregnant women. It increases the risk of preterm delivery, placenta abruption, fetomaternal hemorrhage, and pregnancy loss. Motor Vehicle Accidents (MVAs) account for 70% of blunt abdominal trauma, then comes falls and direct assaults.

Evaluating and managing pregnant trauma patients requires knowing some physiological changes in pregnancy.

Physiological changes in pregnancy

  • Maternal blood volume increases at 10 weeks and reaches a peak level at 28 weeks (45%)
  • Mild anemia because of increased plasma volume (plasma > red blood cells)
  • Cardiac output increases by 1-1.5L/min at 10 weeks until the end of pregnancy
  • Heart rate increases by 10-20 beats/min at the 2nd trimester + decrease in the blood pressure (BP) by 10-15 mmHg. This explains the late deterioration in dropping BP; they may lose 30-40% of blood before signs of hypotension
  • Uterine blood flow = maternal mean arterial pressure
  • At 12 weeks, the uterus becomes an intra-abdominal organ, which is susceptible to direct injuries
  • The bladder becomes anterior
  • Gravid uterus causes stretching to the abdominal wall
  • At 18-20 weeks, an expanding mass of gravid uterus causes hypotension in the supine position by compressing the IVC. Avoid placing IV lines in the femoral/lower extremities.
  • Diaphragm elevated 4 cm, which makes the tidal volume increase by 40%, residual volume decreases by 25%, which causes the short apnea time in pregnant patients
  • Splenic injury is a common cause of hemorrhage

Important actions in pregnant trauma patients

  • Apply supplemental oxygen early because of compensation of hypoxia is limited
  • Consider early intubation
  • 50% more fluids are needed for volume replacement
  • At 20 weeks, place wedge under the right hip, tilting to 30 degrees during the transfer on trauma board
  • Early nasogastric tube placement to avoid aspiration
  • Avoid pressors, which causes uteroplacental hypoperfusion

Rhogam (Rh immunoglobulin) and Tetanus Prophylaxis

Administer RhoD (Human Rho(D) immune globulin) to Rh-negative women; 50 mcg for <12 weeks, 300 mcg for >12 weeks. Tetanus prophylaxis is safe but considered as category C.

Images and Radiation Exposure

Do not withhold needed images. The greatest risk to fetal viability from ionizing radiation is within the first 2 weeks after conception and the highest malformation during the embryogenic organogenesis at 2-8 weeks. The risk of central nervous system teratogenesis is highest at 8-16 weeks. A dose of 5 rad is the threshold for human teratogenesis. Plain radiographs is <1 rad. Abdominal CT + Pelvic angio has the highest dose of rad (2.5-3.5). One of the critical problems is the abruption of the placenta, and CT is sensitive for abruption placenta, 86%, and has 98% specificity. The iodine contrast could cross the placenta and causing neonatal hypothyroidism.

Pelvic exam can be done only after performing an ultrasound to determine the placenta location and exclude placenta previa.

Special Tests

Vaginal fluid pH. If the pH is 7, it is amniotic fluid. If the pH is 5, it is vaginal secretions. Ferning on microscope slide = amniotic fluid.

APT ( alkali denaturation) test is qualitative evaluation to determine the presence of fetal Hg in maternal blood.

Kleihauer-Betke test measures fetal hemoglobin transfer to mothers’ blood.

Specific Issues

  • Direct fetal injuries

    It is rare. It can be seen some injuries such as maternal pelvic fractures, direct trauma to the fetal skull.

  • Uterine rupture

    It is less than 1%. It may be seen at late second and third trimester. It is associated with high fetal mortality. The palpation of fetal parts over the abdomen and radiological evidence of abnormal fetal location determine rupture.

  • Uterine rupture

    It is less than 1%. It may be seen at late second and third trimester. It is associated with high fetal mortality. The palpation of fetal parts over the abdomen and radiological evidence of abnormal fetal location determine rupture.

  • Uterine irritability

    The sign of the onset of preterm labor. Avoid using tocolytics; it causes tachycardia for both mother and fetus.

  • Placental abruption

    1-5% from minor injuries, 40-50% of major injuries. Even simple falls can cause sudden fetal demise. Most sensitive clinical findings; uterine irritability, which can be explained by having more than 3 contractions per hour at the ED.

Fetal viability

The fetus will likely be viable at 24 weeks and above.
The normal fetal heart rate is 120-160 bpm. Heart rate below and above these limits is critical. Because ultrasound may not detect placenta abruption, nor rupture or fetal-placental injuries, high-suspicion and close monitorization are necessary.

Cardiotocography (CTG)

4-6 hours will be enough for most of the cases. Persistent contractions or uterine irritability needs an external CTG for 24 hrs. Fewer than 3 contractions per hour could indicate a safe discharge.

Indication for Emergency C-Section

  • Fetal tachycardia.
  • Lack of beat to beat on long term viability.
  • Late deceleration = fetal distress.

C-section has a 75% survival rate in 26 weeks or above. If the fetal heartbeats are present and the procedure was performed early, the success rate is higher.

References and Further Reading

  • Tintinalli, J., Stapczynski, J., Ma, O. J., Cline, D., Cydulka, R., & Meckler, G. (2010). Tintinalli’s emergency medicine: a comprehensive study guide: a comprehensive study guide. McGraw Hill Professional.

 

Cite this article as: AlHanouv AlQahtani, KSA, "Trauma in Pregnancy," in International Emergency Medicine Education Project, October 25, 2019, https://iem-student.org/2019/10/25/trauma-in-pregnancy/, date accessed: May 28, 2023

Against Medical Advice and Elopement

~ iEM Education Project Team ~ Leave a comment

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 document clearly why the patient left and attested that the patient had the mental capacity to make such a decision at that time (Henry, 2013). While some electronic documentation systems have templates in place to assist with this documentation, Table 2 provides basic information for against medical advice (AMA) discharge documentation that can be used to create a uniform template (Henry, 2013; Siff, 2011; Levy, 2012; Devitt, 2000).

What to do?

Interventions in the ED Discharge Process

DomainIntervention
ContentStandardize approach
DeliveryVerbal instructions (language and culture appropriate)
Written instructions (literary levels)
Basic Instructions (including return precautions)
Media, visual cues or adjuncts
ComprehensionConfirm comprehension (teach-back method)
ImplementationResource connections (Rx, appointment, durable medical supplies, follow-up)
Medication review

An attempt should be made to provide the patient with appropriate discharge instructions, even if a complete diagnosis may not yet be determined. Include advice for the patient to follow up with his physician, strict return precautions, and concerning symptoms that should prompt the patient to seek further care. It should also be made clear that leaving against medical advice does not prevent the patient from returning to the emergency department for further evaluation if his symptoms worsen, or if he changes his mind. Despite a common notion to the contrary, simply leaving against medical advice does not automatically imply that physicians are immune to potential medical liability (Levy, 2012; Devitt, 2000). If a patient lacks decision-making capacity to be able to adequately understand the rationale and consequences of leaving AMA and his condition places him at risk for imminent harm, involuntary hospitalization is warranted. In unclear circumstances and if available, psychiatry can assist in determining capacity, especially in the case of patients with mental health conditions.

Elopement is a similar process where 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, attempt to reach the patient by phone to discuss his elopement and any additional care issues or concerns. Documentation of these attempts or any additional conversation is very important (Henry, 2013; Siff, 2011).

To Know More About It?

Read "Discharge Communications" Chapter

References

  • Brooten J, Nicks B. Discharge Communications. In: Cevik AA, Quek LS, Noureldin A, Cakal ED (eds) iEmergency Medicine for Medical Students and Interns – 2018. Retrieved February 27, 2019, from https://iem-student.org/discharge-communications/
  • Henry GL, Gupta G. (2013). Medical-Legal Issues in Emergency Medicine. In Adams (Ed.), Emergency Medicine Clinical Essentials, 2nd Ed; 1759-65. Philadelphia, PA: Elsevier.
  • Siff JE. (2011). Legal Issues in Emergency Medicine. In Tintinalli’s (Ed.), Emergency Medicine, 7th Ed; 2021-31. McGraw-Hill.
  • 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.

Communication is the key!

~ iEM Education Project Team ~ Leave a comment

Reflections by Vijay Nagpal and Bret A. Nicks

While many believe the environment of care is the greatest limiting factor as opposed to quality communication, literature would suggest otherwise. Establishing a positive patient-provider relationship is essential for patient care. One must recognize that while you may not be able to solve the patient’s condition or chronic illness, using effective communication skills and providing a positive patient experience will assuage many patient fears (Mole, 2016). Keep in mind, in general, patients remember less than 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) (Helman, 2015).

Patients remember

What you say
Web Designer 10%
How you say it
38%
How you look saying it
55%

Effective provider communicators routinely employ these 5 Steps

1

Be Genuine

We know it. People can sense the disingenuous person – whether it is a gut feeling or through other senses. Try to see the situation from the patient’s perspective, and it will ensure that you are acting in his best interest and with integrity.

2

Be Present

As emergency providers, we are interrupted more than perhaps any other specialty. However, for the few moments that we are engaged with the patient or his family, be all in. If there is a planned interruption upcoming, make it known prior to starting a discussion. Be focused on them and the conversation; 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 he talks. After introducing yourself, inquire about the patient’s medical concern; give them 60 seconds of uninterrupted time. Most patients are amazed and provide unique insights that would otherwise not be obtained. Once the patient has provided you with his concerns, begin asking the specific questions needed to further differentiate the care needed. 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, enabling 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. Trust is also built on engaging in culturally acceptable interactions (Chan, 2012) such as a handshake, affirming node, hand-on-shoulder, or engaging posture.

5

Communicate Directly

Ensure that at the end of your initial encounter 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 his care and ask further questions regarding his workup and treatment plan. Additionally, helping the patient to understand what to expect while in the department can help to alleviate fear associated with unannounced tests or imaging studies, especially when these tests may require him or her to be temporarily taken out of the department (e.g., a trip to the CT scanner).

Many of these concepts have been identified in patient satisfaction and operational metrics. In one study, wait times were not associated with the perception of quality of care, but empathy by the provider with the initial interaction was clearly associated (Helman, 2015). In addition, patient dissatisfaction with delays to care is less linked to the actual time spent in the ED and more with a to set time expectations about the care process, a perceived lack of personal attention, and a perceived lack of staff communication and concern for the patient’s comfort.

To learn more about it

Read "Communication and Interpersonal Interactions" chapter

References

  • Nagpal V, Nicks BA. Communication and Interpersonal Interactions. In: Cevik AA, Quek LS, Noureldin A, Cakal ED (eds) iEmergency Medicine for Medical Students and Interns – 2018. Retrieved February 15, 2019, from https://iem-student.org/communication-and-interpersonal-interactions/
  • 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.
  • 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.