Team Dynamics in the Emergency Department
Team dynamics play a vital role in the emergency department (ED) because teamwork and coordination allow for the highest-quality care possible. Individual skills are important, but without teamwork, the best level of care will never be achieved. As an ED technician (EDT), you play a critical role as a member of an interdisciplinary team. Depending on the scope of your practice and your training, the tasks you perform facilitate the treatment of patients and enable the rest of the team to perform their roles successfully.
Communication and Patient Safety
Communication is the transfer of information from one person to another. In an ED, information must be transmitted quickly and efficiently because lives are on the line. Therefore good communication skills are necessary to be an effective team member. Good communication enhances patient safety and reduces the chance of medical errors. In the ED, good teamwork and communication allow for everyone to work together effectively and use all possible resources, which leads to the best patient outcomes.
The Joint Commission is an accrediting body that was established to assess healthcare organizations with the ultimate goal of improving patient care. Their stamp of approval shows that an organization is compliant with national standards for quality of care and patient safety. In their research, they found that communication errors were the cause of 60% of sentinel events (patient safety events that result in death, permanent harm, or significant temporary harm). In these cases, it was the team’s failure to communicate well that resulted in serious harm to the patient.
The ED is a dynamic and fast-paced workplace environment where decisions need to be made quickly. Working with such constant activity may lead to errors that cause patient harm. For example, critical information about patients can be missed, or the wrong dose of a medication may be administered. As a result, various systems have been put into place to help reduce medical errors and improve patient outcomes. One such system is TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety. TeamSTEPPS is an initiative by the Agency for Healthcare Research and Quality, Department of Health and Human Services, and Department of Defense designed to improve patient safety using an evidence-based teamwork system. The system relies on five key principles: team structure, communication, leadership, situation monitoring, and mutual support.
Team Structure
When caring for a patient, multiple teams must work efficiently together to provide the highest-quality care and ensure patient safety. The ED patient care core team is typically made up of physicians, physician assistants, nurse practitioners, nurses, and technicians. The core team is assisted by the coordinating team and other support services. The coordinating team can be thought of as the attending/supervising physicians and the charge nurse. Their role is to oversee and coordinate care for all of the patients in the department. The support services include everyone outside of the core that may be required to assist in the care of the patient. This includes specialists, medical imaging, clerks, and environmental services, among others. All of these roles are supported by the hospital administration, which creates policies and procedures for the hospital staff to follow. As a new EDT, it is helpful to understand the team structure of the ED, as it will help you navigate your new workplace.
Communication
The role of communication between staff members is to relay critical information to other members of the care team. Nurses and providers should promptly be made aware of any important changes in the patient’s status. For example, if a patient develops a new symptom or develops abnormal vital signs, it is important that whoever notes this information shares it with the entire team. Ensuring that all team members are current on the patient’s condition as it changes throughout their ED stay enables providers to make well-informed decisions and respond appropriately to the needs of the patient.
Critical patients often arrive by ambulance. Prior to arrival, emergency medical services (EMS) will radio in to the ED with important information concerning the patient’s condition. This includes the patient’s complaint (why the ambulance was called) and condition (e.g., “alert and oriented” or “unresponsive”), vital signs, electrocardiogram (ECG) results, and any other critical information (e.g., trauma requiring imaging, surgeons, anesthesia, and an operating room) that will help the ED prepare for the patient. Before the patient’s arrival, the ED team will have a huddle . During the huddle, the team leader will identify themselves, and each member will introduce themselves and state their roles and specific responsibility. For example, “Noah, EDT, IV [intravenous] access.” If members do not already have assigned responsibilities, the team leader will assign them. The team leader is responsible for making sure that all providers know their roles and have the proper skill level to perform them. If a provider is not able to perform the assigned role, they must inform the team leader immediately so a different assignment can be made. During the huddle, the team leader will also provide the team with the information provided by EMS and state the patient management plan.
Effective communication is complete, clear, concise, and quick. Only state the relevant information and avoid superfluous details. Use standard terminology and not acronyms. Be brief. Never delay giving information. Last, make sure the information is received with verbal confirmation from the receiver. Critical situations are often noisy, which is why call-outs are used. A call-out is meant to provide critical information to all team members in the room. The team leader will either request certain information, or a team member will provide new information as it is available. Here is an example:
Leader: “Are the pads on the patient”
Technician: “The pads are on the patient.”
Leader: “Thank you, pads are on”
Information must always be acknowledged by the receiver. This is called closed-loop communication . Closed-loop communication occurs when a sender calls out information to a specific receiver and the receiver confirms back to the sender that the instruction has been received and when the action has been completed. This communication method reduces errors by making others aware of the information or instructions and confirming that the information or instructions are received and acted upon. Here is an example:
Leader: “Kamilla, administer 1 mg of epinephrine.”
Nurse: “Administering 1 mg of epinephrine.
Nurse: “1 mg of epinephrine in.”
Notice that the leader named the team member to whom the instructions were directed. This helps avoid ambiguity and confusion.
Closed-loop communication also allows for the receiver and other team members to clarify instructions, thereby reducing medical errors. Here is an example:
Leader: “Kamilla, administer 10 mg of epinephrine.”
Nurse: “Did you mean 1 mg of epinephrine?”
Leader: “Yes. Thank you. Administer 1 mg of epinephrine.”
Nurse: “Administering 1 mg of epinephrine.”
Nurse: “1 mg of epinephrine in.”
In critical situations, you will often overhear providers discussing the patient’s condition. They typically use the SBAR method, which stands for situation, background, assessment, and recommendation. It is a technique mainly used by providers to summarize the critical information and develop a plan of action.
Situation: Describe the problem.
“The patient is unresponsive and his wife said he was shaking his whole body and then lost control of his bladder.”
Background: Overview of the situation.
“He has a history of diabetes. EMS found his blood sugar to be 30 mg/dL. He received 1 amp of glucose in the field, but he is still altered.”
Assessment: Provider’s determination of the problem.
“The patient potentially had a seizure secondary to hypoglycemia. However, the cause of his persistent altered mental status is unclear.”
Recommendation: Plan of action.
“Closely monitor the patient’s blood sugar and vital signs, obtain a full set of labs including a toxicology screen and cultures, and let’s get a STAT head CT.”
One of the most important staff-to-staff communications comes when care is transferred from one provider to another. At shift change, a hand-off is performed and the outgoing technician provides a summary of each patient’s case to the incoming technician. It is important to include the following Chief complaintAny pertinent medical historyImportant findings from their evaluationAny remaining workup orTasks requiring attentionCritical items to be aware ofThe sickest patients, those needing the most attention, should be identified. Last, it is helpful to identify any patients who have particular challenges or needs to better prepare the incoming technician.
Leadership
Team leaders are typically medical providers. In critical situations, their primary goal is to organize an efficient and effective team. During the huddle, the team leader ensures that all roles are assigned to team members capable of fulfilling their specific roles. Once everyone is assigned a role, the team leader will determine the specific plan of action and prioritize certain tasks. As the situation unfolds, it is the job of the team leader to collect information from team members through call-outs, analyze the environment for any issues or changes to the patient’s status, and frequently announce the current patient status. By continually receiving information, they can make any necessary changes to the plan of action. Should anyone in the room have any concerns, or if team members have conflicting opinions, it is the team leader’s responsibility to resolve the conflict and get all of the team members on the same page.
When the critical situation is over, the team leader will direct a team debriefing. They will summarize the events that occurred and highlight what went well and what could have been better. They will also call for input and feedback from team members. The goal of a debrief is to identify any negative or positive events that occurred. Identifying and discussing the negative events, and how they could have been better or avoided improves team member knowledge and skills. Identifying and discussing the positive events, what went well and why, reinforces good behaviors and skills.
You can also be a leader in your specific role as an EDT. By modeling professionalism and excellence in your role, you set the tone for your department, your team, and your fellow technicians. As a positive role model among your peers, you become an ambassador for your institution and your profession. Be proud of your role in the team, and look for opportunities to excel as a leader.
Situation Monitoring
Situation monitoring involves constantly examining your environment, being aware of the actions of your peers and the status of the patient, and providing feedback to assist the team’s performance. STEP is an acronym to assist you in remembering what needs to be monitored.
Status of the patient: What are the patient’s vitals? How does the patient appear? What is the patient’s status?
Team members: Are your teammates accomplishing their tasks? Do they need assistance?
Environment: Is something impairing your team’s performance? Are there too many people in the room? Are you missing equipment?
Progress toward the goal: Have you stabilized the patient? Are your interventions working?
Examining and synthesizing what is occurring around patient care creates situational awareness . It is an active process and cannot be done passively. Everyone in the room must constantly be engaged in situation monitoring because it helps to keep everyone safe, including the patient and team members. When all team members are practicing situation monitoring, are situationally aware, and are communicating all pertinent information, the team has a shared mental model . This means that all team members have the same mind frame: they know what is happening and what the plan is. The team leader is vital in ensuring that a shared mental model is formed. They are constantly collecting information (situation monitoring), analyzing it (situational awareness), and sharing it with the team (communication).
Mutual Support and Advocacy
Emergency medicine is practiced as a team. EDTs technicians continually provide task assistance to colleagues toward the common goal of optimal patient care. Nurses have many different responsibilities and are often inundated with multiple different tasks for a variety of patients. Therefore, proactively taking responsibility for tasks within your scope eases their workload and builds teamwork. As you work in the ED, your ability to anticipate what patients will need and how to support your nurses will improve.
In critical situations, task assistance happens frequently. As a team, each person helps each other complete tasks, resulting in higher-quality care that is completed faster. For example, while you are getting IV access on one arm, a nurse who has finished their task may start looking for IV access on the other arm. Fostering a collaborative work environment where colleagues are willing to seek and offer assistance is an important component of teamwork that results in high-quality care.
The second component of mutual support is advocacy . Technicians are responsible for the health and well-being of patients and must advocate on their behalf. Unfortunately, an ED can be a busy and even chaotic environment and sometimes a patient’s needs can go unnoticed. If you see a patient in pain or if you recognize that the patient requires nursing or provider attention, advocate for the patient by notifying a nurse or provider.
In critical situations, advocating for a patient may require speaking up when something is wrong or asking a clarifying question. For example, an unresponsive patient with pulses is brought in by EMS. The patient is put on the cardiac monitor, IV access is established, defibrillator pads are put on, and vital signs are taken. While the other team members are busy completing their tasks, you notice that the patient has lost a pulse. It is your responsibility, using a clear and assertive tone, to let the team leader know that the patient has lost a pulse and that cardiopulmonary resuscitation must be initiated. This concern must be voiced until you have verbal confirmation that you have been heard by the team leader .
Advocating for patients can be a daunting task as there is a well-established healthcare role hierarchy. Technicians work under nurses and providers. Although technicians do not have final medical decision-making authority, everyone is equally responsible for a patient’s well-being. Therefore, if a situation requires you to speak up, you must do so. Inexperience is no excuse not to voice concerns or ask clarifying questions. When voicing a concern, use “alert language” (e.g., “concerned,” “uncomfortable,” or “patient safety”). This will notify the team leader and others that there may be a problem that requires immediate attention.
Identifying medical errors does not mean that you or the team will face punishment, rather the opposite. Your insight and your role in the team may expose something important that no one has addressed. As an EDT, you will find yourself in certain situations that will require you to speak up, and your ability to participate in effective communication may end up saving someone’s life.
The five key principles of TeamSTEPPS (team structure, communication, leadership, situation monitoring, and mutual support) are proven evidence-based systems that optimize team performance in the healthcare setting. Working on these skills enables high-quality staff-to-staff communication resulting in enhanced patient safety and a reduction in medical errors.
Patient Communication
The first interaction with patients typically occurs when you enter their room to start a workup. A helpful model for an initial patient interaction is the Studer Group’s AIDET model . AIDET stands for Acknowledge, Introduce, Duration, Explanation, and Thank you . Acknowledge by greeting the patients and family members as you enter. Greeting patients with a smile puts them at ease and demonstrates that you are there for their care. Introduce yourself with your first name, title, and your role of technician. Using a first name is more informal and helps to connect with patients on a more personal level. Often, patients are familiar with doctors and nurses, but they do not know what a technician does. An example introduction would be, “Hi, my name is Noah. I am a technician here and I work with everyone taking care of you today.”
Next, let the patient know what to expect during the duration of their stay. Identify next steps and the process of an ED visit. Be specific when possible, but when this is not possible, let the patient know that you will (or another member of the team will) provide them with information as it becomes available. One of the most stressful parts of an ED visit is the waiting experienced by the patient. Recognizing that this is a concern for them establishes trust between you and the patient and alleviates frustration for the families.
Then, tell the patient and family what you are going to do and give an explanation as to why they are being done. It is OK to say that you are not sure and that you will have the provider or the nurse provide further details. Always end by asking the patient for consent to perform the procedures ordered, as they have the autonomy to refuse services if they are of sound mental status. An example explanation would be, “The doctors ordered some blood work so I’m going to get an IV started. They also want an ECG to see how your heart is doing. Is that OK with you?” Most patients will allow you to proceed; however, if the patient refuses any or all of your workup, it is their right to do so. You can then offer to answer any additional questions or provide a further explanation. If the patient continues to refuse, respect their autonomy and inform the nurse and provider.
The next time you enter a room might be to collect blood work, obtain vital signs, or bring someone to medical imaging. Always obtain a patient’s consent before doing anything to them. Often, patients ask for test results or if you know why they are sick. Informing patients of test results is typically left to the providers.
Finally, say thank you. Thank them for being patient during difficult procedures, interventions, and wait times. Expressing gratitude and empathy to your patients and their families shows that you are there to support them and can improve their overall experience in the ED.
Language and Barriers
Patients who do not speak or have limited English proficiency (LEP) are particularly at risk for communication errors. All hospitals receiving federal assistance (including Medicare and Medicaid reimbursements) are legally required by the Affordable Care Act to provide all LEP patients with a qualified (typically certified) medical interpreter in person, by phone, or through a digital platform. Any bilingual staff member who translates for a LEP patient must be formally trained to do so and oral translation must be listed in their job description. Bilingual staff and English-speaking family members who accompany non-English speaking patients may assist the patient, especially in emergent situations where a translator is not immediately available; however, they are not to be relied upon for translation once a translator is obtained.
When relying on family members or friends to translate, keep in mind the following barriers to care:
Privacy: The patient may not want to share sensitive or personal information with the
family member. They may be forced to give up their right to privacy or provide inaccurate information to protect their privacy.
Medical terms: Medical terms may not be understood or interpreted correctly by the translator, which can lead to significant medical error and patient harm.
Coercion: The patient may feel inappropriately pressured by the translator to accept or decline certain medical interventions based on costs, beliefs, or other factors.
Special Needs
Under the Americans with Disabilities Act, hearing impaired and deaf patients must legally be provided “effective means of communication.” These patients must be asked for their preferred method of communication. A majority of deaf people in the United States use American Sign Language (ASL); however, some may prefer to communicate in writing, especially those with newer hearing loss. Other patients may be able to lip-read and respond verbally. Most hospitals have access to ASL interpreters in person or through a digital platform. Effective communication with visually impaired patients can often be done verbally. As long as effective communication can be achieved, then no special interpreter needs to be provided. However, a blind and deaf patient must be provided a tactile interpreter or some other form of translation services, such as a Screen Braille Communicator, to ensure effective communication.
Health Literacy
Health literacy describes the degree to which a patient can understand complex medical information and terminology in a way that they can use that information to make informed decisions and take appropriate actions concerning their health. Poor health literacy can be attributed to multiple factors including low socioeconomic status, insufficient education, LEP, cognitive barriers, and cultural obstacles (e.g., lack of culturally appropriate information). Patients with poor health literacy have substantially worse health outcomes. Because it is not always apparent which patients may struggle with health information, all patients should be spoken to in a straightforward and respectful manner using words and concepts that are easy to understand. Refrain from using overly complicated medical terminology, acronyms, and the like. Explain procedures in lay terms. For example, instead of saying, “I’m going to obtain a troponin,” simplify by stating that you are going to draw some blood for a test that can show if there has been any sudden injury to the heart. Create a safe and nonjudgmental space by asking patients if they have any questions and proactively offering to explain anything they may not understand.
Body Language
Although often overlooked, nonverbal cues are an important form of patient communication within the hospital setting. It is important to pay attention to your body language, including facial expressions, gestures, body positioning, tone of voice, and eye contact. When interacting with patients, try to maintain a relaxed stance, or sit across from them so as not to talk down to them. If a patient is talking to you, devote your full and undivided attention and actively listen. Never cross your arms in front of patients, roll your eyes, or take out your cell phone while patients are speaking with you. These actions make you appear uninterested and unreceptive to the patient’s concerns. Consider the patient’s nonverbal language as well. If the patient is cueing that they are frightened, avoidant, defensive, or in pain, recognizing these signs enables improved communication and care.
Communication Systems and Technology
As technology has revolutionized the world we live in, so too has it changed the way we communicate in the ED. There are three primary ways that healthcare providers communicate with one another throughout the hospital setting. Hospital radiofrequency (RF) phones and tablets allow staff to communicate urgent or important information through calls or texts via a dedicated network. Encrypted smartphone applications that are compliant with the Health Insurance Portability and Accountability Act (HIPAA) may be instituted hospital-wide, enabling staff to use their own phones as a secure means of relaying important patient information through text messages. Computer- and tablet-based electronic medical record (EMR) programs serve as an electronic form of the patient’s chart, documenting their care as they receive it. The EMR is the legal record of a patient’s healthcare. Most EMRs provide a way to enter comments or notes for communicating useful nonemergent information that is outside of the permanent patient record. For example, if a patient is taken to x-ray, the technician would note to the team that the patient is in x-ray. Hence, when the nurse goes into the patient’s room, they know that the patient is in x-ray as opposed to eloping or being in the bathroom for a concerningly long period of time. Often, multiple forms of electronic communication are used within the hospital, and together they play a critical role in improved patient care.
Conclusion
As an EDT, you are an integral part of the team providing direct patient care. Your ability to treat everyone with respect and empathy and maintain your professionalism will establish trust with your team and patients. Your adherence to safety using the TeamSTEPPS approach, closed-loop communication, good patient communication, and knowledge of your scope of practice and hospital policies ensures that you are performing to the highest level of your role. Whether your goal is to be a lifelong EDT or to use this opportunity as a stepping-stone in your career, you are a vital part of the ED team in delivering excellent and competent care.
References for Additional Reading
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The Role of the Hospital Emergency Department and the Specialty of Emergency Medicine
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