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Emergency Medicine

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Studies examine emergency communication, use of defibrillators, and benefit of ED pharmacists

Paramedics and emergency department (ED) clinicians are bombarded with information as they struggle to care for critically ill or injured patients in often chaotic circumstances. Good communication, skill in using lifesaving devices, and selection of the right medications help them to save lives both in and outside of the ED.

Three studies supported by the Agency for Healthcare Research and Quality (HS15818) and led by Rollin J. Fairbanks, M.D., M.S., of the University of Rochester School of Medicine, recently examined these issues. The first study found that ED communication is typically quick, face-to-face, and varies among types of ED providers. The second study showed that paramedics perform better on a new generation cardiac defibrillator than the older one, but there are still some problems. According to the third study, ED nurses and doctors highly value having an ED pharmacist to consult. The studies are described here.

Fairbanks, R.J., Bisantz, A.M., and Sunm, M. (2007, October). "Emergency department communication links and patterns." Annals of Emergency Medicine 50(4), pp. 396-406.

This study observed the communication patterns of 20 staff members in the pediatric and adult ED areas of a regional hospital trauma center over the course of 39 hours (including day and evening shifts). Most communication was face-to-face, short (less than 1 minute to 3 minutes), and frequent (an average of 49 communication events per hour). However, the frequency, duration, and mode of communication differed among ED providers. For example, paramedics and triage nurses didn't communicate often with ED attending doctors. This suggests that the attending doctors received most patient handoff information secondhand.

Attending physicians communicated often with each other, despite caring for separate patients, possibly for second opinions about difficult cases or to coordinate ED care management. All nurses, but especially the charge nurses, seemed to be the hub for communication, linking ED personnel with non-ED staff. All ED providers in the adult area carried wireless phones. However, in the pediatric area, only the attending physicians and charge nurses had wireless phones.

Interruption rates (one cause of skill-based medical errors) in the adult areas ranged from 6.9 per hour for attending physicians to 0.5 per hour for bedside nurses. In the pediatric areas, interruptions ranged from 3.6 per hour for the attending physicians to 0.3 per hour for bedside nurses. Junior physician residents spent much of their time reading and writing on the whiteboard (patient status board that tracks patients and caregiving tasks), which suggests they used it as an organizational tool. This information about ED communication patterns may help identify information technology solutions to enhance ED communication and emergency patient care.

Fairbanks, R.J., Caplan, S.H., Bishop, P.A., and others (2007, October). "Usability study of two common defibrillators reveals hazards." Annals of Emergency Medicine 50(4), pp. 424-432.

Cardiac defibrillators are used to shock the heart, when there is an irregular (fibrillation) or abnormally rapid (tachycardia) heartbeat. The Lifepak12 cardiac defibrillator is the newer-generation replacement for the Lifepak10. Although the Lifepak10 is easier to learn, the Lifepak12 is easier to use and more effective in emergencies, according to the 14 paramedics who completed 4 out-of-hospital simulator scenarios using each device.

The scenarios ranged from simple electrocardiogram (ECG) monitoring to shocking the heart of a patient with confirmed ventricular fibrillation, synchronized cardioversion (deliver two sequential shocks at a specific time in the cardiac cycle for patients with unstable tachycardia), and replacement of defibrillator paper for the cardiac rhythm readouts.

The experienced advanced life support paramedics rated the Lifepak10 easier to use than the Lifepak12 to perform a quick look (mean of 8.0 vs. 7.1 out of 9) and rated the Lifepak12 easier to use for synchronized conversions (mean of 6.7 vs. 5.3). They performed better on the Lifepak12 than the Lifepak10 for synchronized cardioversion (mean of 3.1 vs. 1.6) and replacing paper (mean of 3.0 vs. 2.1). Most (85 percent) of the paramedics preferred use of the Lifepak12 on a regular basis. Nevertheless, paramedics had difficulty using the devices with gloves and were confused about the "sync" mode. For example, during the simulations, half of the paramedics inadvertently delivered an unsynchronized countershock for supraventricular tachycardia, which can cause ventricular fibrillation. This high failure rate in synchronized cardioversion indicates a need to reevaluate the user-defibrillator interface design for this function.

Fairbanks, R.J., Hildebrand, J.M., Kolstee, K.E., and others (2007, October). "Medical and nursing staff highly value clinical pharmacists in the emergency department." Emergency Medicine Journal 24, pp. 716-718.

Few emergency pharmacist (EPh) programs exist, despite their potential to improve medication safety and quality of care in the ED. ED doctors and nurses highly value the presence of an EPh in the ED, often seek their advice, and feel that they improve ED care quality, according to this study. The researchers surveyed a random sample of medical and nursing staff at the ED of a large medical center with a dedicated EPh program. Nearly all respondents (99 percent) thought that the EPh improved quality of care, 96 percent considered them an integral part of the team, and 93 percent had consulted the EPh at least a few times during their last five shifts.

The ED doctors and nurses also believed that the EPh should be available for consults, to attend resuscitations, and to check medication orders. Finally, these emergency professionals preferred that high-risk and rarely used medications be checked by an EPh when possible. Clinicians who cared for children believed that a mandatory review of certain pediatric medication orders would improve medication safety. Nearly all ED physicians and nurses considered the EPh to be helpful with medical and trauma resuscitations, review of medications, and as a patient educator.

These findings reinforce the value of the EPh program, and demonstrate that staff acceptance is clearly not a barrier to program implementation.

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