Communication

Communication is the process of information exchange and is a central and critical aspect of our care of patients in the ED. As providers, we must solicit and receive information, establish the diagnosis, understand the social situation, and make an appropriate plan for care. In addition, we must provide our patients with information to facilitate understanding of their treatment and diagnosis, improve adherence to instructions, and ensure good outcomes.

Communication has two major components: verbal and nonverbal. These components work together and complement one another, with both having an impact on information exchange.

Verbal communication in our interactions with patients includes several key elements:

Nonverbal communication is just as powerful as verbal communication with respect to its impact on patient-provider interactions. Facial expressions, body language, and physical space or touch are several aspects of nonverbal communication. Although nonverbal communication is more subtle and may seem less vital than verbal communication, it is essential to recognize the importance of nonverbal elements and their role in supporting or undermining the words that we use. This component is particularly critical in our efforts to convey courtesy, compassion, and respect.

Nonverbal communication in our interactions with patients has several key elements:

Operational Considerations

Interactions between providers and patients progress through several important stages of the ED visit. Provision of PCC relies on effective engagement of patients during each of these critical junctures. Although a systems approach to PCC is discussed later in this chapter, some practical considerations for incorporating patient-centered care into daily practice are reviewed here and include examples of appropriate phrases and statements for each stage of the ED visit.

Humanistic Considerations

An additional core element of PCC is the consideration of a patient’s illness and signs and symptoms in the larger context of the patient’s personal experiences and background. As providers, we are well aware that similar illnesses or conditions can yield diverse reactions and responses in different patients or populations. These differences reflect variation in patients’ personal views, cultural beliefs, preferences, values, past experiences, and fears. Provision of PCC means simply that we do not disregard these differences but, instead, actively seek to understand them, embrace them, and incorporate them into our clinical practice and plan of care. We should view each patient as an individual (not a disease process or diagnosis) and recognize that each brings a unique story and circumstance to the ED.

In the real world, these humanistic elements of PCC are often met by important challenges. We discuss these issues here and consider how one can begin to recognize and minimize such barriers to the practice of PCC in a busy ED.

Patient Satisfaction

Satisfying patients is at the core of developing a culture that is patient centered. Although many providers will summarily dismiss the value of the patient’s perception of the care rendered, this viewpoint is only partially valid and is misguided. Certainly, patients are not qualified to judge the technical adequacy of the medical care provided. However, they are more than qualified to judge whether the system and providers cared about their comfort, communicated their treatment plans, addressed their pain, and informed them about wait times and delays. It should not be a surprise to anyone that these same concepts are represented in almost every commercial and noncommercial patient satisfaction survey tool currently in use.

So, EDs need to be in the business of making patients happy. Those that are not will quickly learn that their competitors are more than happy to do so. The ED is the operational “front door” of most hospitals. In 2008, the National Ambulatory Medical Care Survey, 2006, reported that the ED was the source of 50.2% of all nonobstetric admissions to U.S. hospitals. Furthermore, if an ED is not interested in making a good impression on the community and embracing patient satisfaction as a core competency, many chief executive officers will look for ED staffing solutions that will provide the appropriate emphasis on this important goal. Although individual interactions can be standardized and scripted to improve patients’ experience, as discussed previously, operational efficiency goes a long way toward pleasing patients.

Common themes in the literature are that provider interpersonal communication skills, delivery of information and explanations, and perceived wait times most strongly correlate with patient satisfaction. Although actual wait times are less likely to predict satisfaction or a lack thereof, patients with a length of stay of 8 hours are generally less satisfied than their counterparts waiting only 4 hours.¹⁴ Operational efficiency is not only critical to ensuring patient satisfaction but is also a key factor associated with a patient-centered approach to care.

Operational Efficiency

Operational metrics such as overall length of stay, door-to-provider time, provider-to–decision making time, and decision making–to-disposition time are nationally recognized measures of operational efficiency. These metrics should be measured and performance improvement initiatives tailored toward a more efficient experience for the patient.

Operational efficiency not only provides a positive impact on patient satisfaction but also promotes patient safety; both are critical to PCC. In other words, patients are happier when they are seen more quickly and have a shorter length of stay. In addition, when throughput is more efficient, an ED’s bed capacity can be used more effectively, more patients can be seen, patients who leave without being seen can be avoided, and the likelihood of deterioration of patients in the waiting room can be reduced. For instance, if the average length of stay for admitted patients is 6 hours in one ED versus 3 hours in another, with both seeing 50,000 patients a year and having 40 ED beds and an admission rate of 50%, 205 patient care hours would be saved in the more efficient ED on a daily basis. Thus, the more efficient ED can see 68 more admitted patients than the less efficient ED. Of course, the operational efficiency of admitted patients is dependent on many factors inside and outside the ED.

A truly patient-centered culture will address ED crowding and ED boarding of admitted patients as a hospital system issue, not an isolated ED issue. We know that boarding often results in inefficient bed management in the hospital and leads to delays in the time that it takes to execute a decision for admission. A policy statement released by the ACEP in January 2011 clarified the definition of boarded patients:

“In order for emergency departments to continue to provide quality patient care and access to that care, ACEP believes a ‘boarded patient’ is defined as a patient who remains in the emergency department after the patient has been admitted to the facility, but has not been transferred to an inpatient unit.”

Furthermore, it has been proved that the heavy demand on ED resources during times of crowding is an impediment to providing high-quality care and compromises patient safety. Although a thorough discussion of throughput metrics is beyond the scope of this chapter, it is important to note the critical nature of these metrics when considering the patient as the primary stakeholder in these processes.

The time from decision making to actual disposition (departure from the ED) may be viewed by many as being beyond the control of the ED, as well as by many institutions that do not view boarding as an institutional issue. However, intake is a process that is solely owned by the ED. Yes, intake processes are adversely affected by boarding and lack of availability of hospital resources, but nimble EDs can create the necessary “work-arounds” to stay patient centric in their approach. Bedside registration is an excellent tool to improve door-to-bed times. Registration is often a non–value-added step, from the patient’s perspective, that is frequently placed ahead of patient care. Not only does this have potential Emergency Medical Treatment and Active Labor Act (EMTALA) implications, it also delays the care provided. Because there is often considerable downtime during an ED visit, it is ideal for the registration process to be conducted during these times, not at the critical front-end portion of the visit. Some would argue that care cannot begin until a chart can be generated and ordering in the hospital’s information system can begin. This argument holds no water because very little information is actually needed to generate a patient identification capable of initiating care, and this information can be obtained during the triage process.

The shortfall is that bedside registration does not ensure that a provider will get to patients any quicker than if they were in the waiting room. Thus this may not affect the more important metric of door-to-provider (doctor) time. However, placing a provider in triage does. Whether a physician or midlevel provider, placement of a provider at triage with the nurse can initiate the visit without the need for formalized ED bed placement. Furthermore, many low-acuity patients may be discharged directly from triage, after completion of their care, and never need an ED bed. Standing orders may be a bridge to initiate care. However, standing orders are often overly broad in application and result in unnecessary tests being ordered, and they do not take the place of the provider in evaluating and initiating management of the patient.

Medical-Legal Factors

The two primary factors associated with filing medical malpractice claims or lawsuits are bad patient outcomes and unhappy patients. Although the relatively frequency of medical malpractice claims is fairly low, with a range of approximately 1 in 25,000 to 40,000 ED encounters, it is difficult to find definitive correlations between patient satisfaction and lawsuits. However, the preponderance of the literature more than strongly suggests that poor patient satisfaction results in more patient complaints. Additional data suggest a strong correlation with patient complaints and risk management events and medical malpractice lawsuits. In one study, a 1-point decrease in patient satisfaction survey results correlated with a 6% increase in the incidence of risk management events (claims, lawsuits, and incident reports). In this same study, 75% of 483 claims were associated with communication errors, thus emphasizing the need for improved communication between patients and providers.¹⁵ Patients who are well informed about their care are less likely to be taken by surprise by changes in their condition, medication side effects, and failure of treatment. To that end, treatment and diagnostic plans should be discussed with patients and their significant others, results should also be discussed with them, therapeutic response to treatments needs to be assessed, and final disposition plans need to be discussed and agreed and comprehension acknowledged and confirmed. Although many busy EDs defer some of these tasks to nursing, it is of vital importance that the physician at least reinforce these communications. However, it is ideal for the physician to be the primary provider to conduct communications with the patient.

Patient handoffs are another aspect of a patient-centered culture that is both an operational and a risk management concern. Up to 24% of medical malpractice claims result from faulty handoffs. Handoffs are transitions in care from one provider to another and often from one care setting to another. To ensure that errors are avoided, the quality of care is not compromised, and patient safety is preserved, a standardized approach should be taken to handoffs in the ED. Recommended steps include a face-to-face encounter by the incoming and outgoing providers, an explanation of the active problem list and any outstanding diagnostics, and the expectations for disposition. In addition, it is useful to advise the patient that the handoff is occurring and even introduce the patient to the incoming provider.¹⁶

Yet another new focus on PCC that is intertwined with risk management is error disclosure. Disclosing errors is now a patient safety requirement from the Joint Commission. Concealing medical errors is unethical, immoral, and unwise. Furthermore, every hospital must have a policy outlining the requirements for disclosure of medical errors. The decision to disclose should not be based on the severity of the error or the provider’s perception of patient impact. If the error occurred, the patient has the right to know that it occurred, regardless of how others value the importance of this information. Such a policy should include notification of the hospital risk manager and ED leadership (i.e., medical director, nurse manager). It is also important to note that disclosure is an excellent risk management tool. Appropriate settlements can be reached, litigation avoided, and indemnity and defense expenses reduced. Moreover, if a medical error is concealed and a lawsuit is filed, the error will invariably be identified through the discovery process. Once it appears that the providers intended to “cover up” the error, there is no viable defense, and no jury in the United States will be sympathetic with defendants who were flagrantly dishonest.

Compliance

The federal government has long been interested in PCC. Consider the patient implications with the Civil Rights Act of 1964, the Health Insurance Portability and Accountability Act (HIPAA), and EMTALA. Clearly, the federal government has embarked on many initiatives that are patient centered. The Civil Rights Act requires that any institution accepting federal compensation for rendered care must provide medical interpretive services for limited English-proficient patients. Not doing so is in violation of this statute and may constitute civil rights violations on behalf of the patient. Medical interpreters are not only required to be fluent in the language that they are interpreting but must also have experience in medical interpretation. In other words, finding someone in the hospital who speaks a language (i.e., a Spanish-speaking housekeeper) is not sufficient. It is also important to recognize that the use of family members is not a viable substitute unless the patient refuses formal medical interpretation. If there is a problem, complaint, or bad outcome, the only witness to the interaction between providers and the patient will be the interpreter. It is unwise for that sole witness to be a nonimpartial family member.

HIPAA focuses on the patient’s right to due care being given to their protected health information. This information, sensitive to the patient, must be handled in accordance with this statute to protect the patient’s privacy. EMTALA requires that all patients who go to the hospital, its “campus,” and related buildings with an emergency medical condition have a medical screening examination (MSE) performed, regardless of their ability to pay. The MSE also includes stabilization of any identified emergency medical condition. Thus, through the course of compliance and performing the MSE, the care of most ED patients is completed. Though not a financially viable program for hospitals and emergency medicine, it is certainly a patient-centered initiative that allows access to care for all emergency patients (Box 216.1).

Compliance with federally mandated programs is essential for a hospital to maintain an individual provider’s Medicare provider number. Without these numbers, participation in federally funded programs such as Medicare and Medicaid is prohibited.

Advanced Directives

In the ED setting we frequently care for patients with life-threatening illnesses who are faced with important choices regarding their management. As emergency providers we need to develop skill in helping patients and their families understand their disease and prognosis, consider the acute issues that they are confronting, and make choices that reflect their personal priorities and goals. The process of discussing and establishing goals of care is a large and important topic that incorporates many of the core principles of PCC. Advanced directives represent a critical subset of this area that we encounter frequently and often cannot be deferred to a later time.

As we approach a patient and family for a discussion of advanced directives, we should be guided by the fundamental elements of PCC. We must embrace our patients (and their families) as unique entities and consider their personal story and circumstances as we provide clinical information and guidance in their decision making. With this approach we are able to support the patient and family in choosing the best path for them while recognizing that there is no absolute “right” choice or plan.

Family-Witnessed Resuscitation

Interest in the practice of family-witnessed resuscitation (FWR) began in the 1980s after studies surveying families of survivors of sudden death found that their most frequent criticisms centered on frustrations with inadequate information and updates during resuscitation.¹⁷ Additionally, it was noted that families of critically ill or dying patients often complained about feeling helpless, uninformed, and uninvolved.¹⁸ As a result of these findings and some requests by family members to be present during resuscitation procedures, standard practices excluding families began to come into question.^19,20

Within the field of emergency medicine there has been significant debate regarding whether families should be allowed to accompany their relatives who are undergoing critical resuscitation. Proponents of this practice advocate that family members should have the choice to be present during these desperate efforts, which are often the final moments of patients’ lives. However, many medical professionals are strongly opposed to the idea and cite a wide range of concerns: that relatives will interfere with or misunderstand medical efforts, that the events will be too upsetting for relatives to bear, and that family presence will create additional stress and anxiety for the medical team.^21–25

Research to date demonstrates that families who are allowed to be present during resuscitation procedures recognize the practice as beneficial to both themselves and their ill relatives. Family members perceive their presence as important not only to provide support and reassurance to the patient but also to relieve their own anxiety by reducing feelings of helplessness and the “agony of waiting.”²⁶ Relatives also report that being present with a dying loved one eased their subsequent bereavement process.^20,26,27

Research findings also indicate that the anticipated problems or expected complications of FWR fail to occur in clinical practice.^27–29

In recent years FWR has been recognized as being fundamentally consistent with a patient- and family-centered approach to care.³⁰ FWR provides the opportunity to engage and empower a patient’s loved ones during the most critical moments of serious injury or illness. The open door facilitates a connection and partnership between the provider and family that can have significant downstream effects on this relationship and, ultimately, the grief and bereavement process.

In the future, more research is needed to fully assess the consequences of FWR for all participants in the resuscitation process and for different clinical situations and patient populations. However, it is clear that research alone will not resolve this debate because our emotional responses as providers may defy research results. As emergency providers we must focus our energy on helping ourselves and others remain open-minded to the possibility of benefit from these practices and consider their role in our efforts to provide patient- and family-centered care.

Informed Refusal

In emergency medicine we often encounter patients who refuse our recommended care, and our interactions with these individuals can be frustrating and challenging. Many factors can lead to refusal, and ultimately we must accept a patient’s choice to refuse our recommendations. However, when we encounter these situations in our daily practice, a few important concepts should be considered.

First, we must work hard to ensure that we use the basic principles of PCC in our efforts to discuss this issue with our patients. We must explore the situation from their perspective—their past experience, social circumstances, fears, and anxiety—to help us understand the factors that are leading to their refusal. Second, we must set aside our personal reactions and feelings as we engage in these interactions. In particular, we cannot allow our own emotions and responses to patients prevent us from making a genuine effort to connect with them and to help them understand how our recommendations may be compatible with their personal views and preferences.

In the end, we must accept that sometimes our efforts will not be successful and we have to understand how to approach these situations. Informed refusal stems from the doctrine of informed consent, and the same basic tenets apply. Patients need to possess the medical decision-making capacity to consent or refuse care (e.g., conscious, alert, and oriented to person, place, time, and situation), and they need to be informed of the risks and benefits of the proposed treatment and the risks and benefits of alternatives, including no treatment at all. Patients need to demonstrate their understanding of this discussion. The standard for informed consent or refusal is what a reasonable patient would want to know. This is vastly different from the former physician standard regarding what a reasonable physician would inform the patient about. Informed refusals should be well documented in the medical record, and it is important to recognize that signing a refusal or against-medical-advice form does not necessarily meet the required elements for informed refusal. Merely signing a form does not document which risks associated with refusal were discussed with the patient.