N4: G’day [to D1].
D1: G’day Elizabeth, my name’s Fred.
P: Elizabeth.
D1: I’m one of the doctors.
P: Alan [N4’s name], Fred, I’m learning.
N4: You are.
D1: What’s been going on?
P: Ooh oh everything.
D1: OK.
P: Ah.
D1: In particular?
P: Well, the oxygen drop is was what Dr D was worried about. And, oh, coughing and I have been a smoker, I’m not denying it. But ever since [chuckles] I had the Vibramycin4 …
D1: Yeah.
P: … I’ve … it seems to have got rid of everything in the nose and my mouth and my lungs, coughing stuff up, but I’m not having – not coughing enough up. I can’t seem …
D1: OK
P: To get it up, so. There’s something obviously – I need a bomb under me.
D1: Sure. Besides the trouble with the breathing, like not being able to get your breath, what are the other problems? Sort of have you got no energy, have you had temperatures?
P: No.
D1: Sweats?
P: Ah, well the last couple of nights I’ve had night sweats.
D1: OK.
P: Very sweaty.
P: And, um, I’ve been too tired to get out of bed and I was nearly gonna get out and have a shower, then I thought ‘no, I’ll get a chill’.
D1: OK.
N4: Ssh.
N4 tells D1 to be quiet and also holds up his hand as he does the ECG reading.
Later in the consultation D1 has trouble getting Elizabeth’s cannula in and he arranges for a more senior clinician to do this for him. This break in the history-taking means that by the time he returns to Elizabeth much later on he needs to go over her history again as he admits he has ‘probably’ forgotten what she told him earlier. He also admits to being confused about her symptoms because he has another patient on the day with a similar condition to hers.
D1: But did you say that – I’m just trying – I’m getting my patients mixed up – you – you feel like there’s more in there than what you’re able to get up …
After this, D1 takes up the conversation again completing the history-taking by asking what medications Elizabeth is on, etc. D1 tells Elizabeth he will proceed with a chest X-ray, have a look at her chest, take some blood and do a few other tests. He informs her he will also ask her to do a spirometry test which she is very reluctant to do.
- history-taking
the process of questioning and observation that a practitioner undertakes to establish what has happened to, or what is wrong with a patient.
Analysis and reflection
During Elizabeth’s stay in the ED, five nurses and two doctors (one junior) care for her. Nurse Peter (N2) is the third clinician Elizabeth engages with, having already spent time with Nurse 1, the triage nurse, and the paramedics. Elizabeth will still need to talk to several other practitioners, including five more nurses, two doctors, one registrar and several radiography staff before she leaves the ED.
- triage
the process of assessing and sorting patients’ illnesses and/or injuries in terms of acuity and urgency, usually undertaken by a nurse at the front desk of an emergency department. The triage category indicates the urgency of the patient’s need for medical and nursing care.
The structure of how ED clinicians engage with Elizabeth appears similar to that of the common patient consultation (Roter, 2000). However, a key difference between the common consultation and the ED consultation is that in the ED patients engage with multiple practitioners, often in rapid succession. This means that ED consultations (if that is the right term), instead of taking place in a quiet office and with the benefit of additional equipment – a computer, phone, printer, and so forth – take place in a very busy environment where colleagues are dispersed and constantly moving (collecting or replacing equipment, rotating between patients), and where noise – loud voices, beepers and overhead announcements – continually interrupt conversations.
As N2 leaves Elizabeth to collect an armband, we note that this is typical of what happens in an ED consultation. When he returns to her bedside, however, he repeats his earlier questions almost exactly as he asked them before, signalling (unintentionally) to Elizabeth that he approaches her not as a person, but instead acts out ‘protocol-based’ routine to information-gathering. Finally, when N2 addresses Elizabeth as ‘Lizzie’, this suggests quite a high level of familiarity, which may not have been appropriate.
Implications for practice
In the above exchange, as in many others, Elizabeth’s practitioners are interrupted in what they are doing (Coiera et al., 2002; Manidis, 2013). To add to this, her clinicians face a number of other challenges. In Elizabeth’s case, D1’s challenges include confusion between her symptoms and another patient’s, and an inability to insert a cannula. N2’s challenges are missing equipment (the armband) and his novice status. For all clinicians, communicating in the ED environment can be very complex.
Despite this complexity, it is critical that clinicians forge continuity of care for the patient. Continuity of care is generally understood as the key to safe and high-quality care. Practice example 5.1 illustrates that continuity of care should not be thought of as just created through clinical handover. Instead, continuity arises from a combination of (1) a clinical handover (as a first stage), (2) effective interprofessional communication, and (3) iterative questioning of the patient to ensure the patient’s situation has not changed significantly, and the same knowledge still obtains (Manidis, Iedema & Scheeres, 2012).
- interprofessional communication
how professionals from different professional backgrounds communicate with one another.
What is further important from Elizabeth’s example above is that when patients like her are re-questioned, nurses and doctors should make clear to their patients why they are repeatedly asking the same questions. For example, N2 could have explained why he was asking Elizabeth for her name and date of birth again. He knew why he was doing it, but Elizabeth didn’t. For her, the repeated questions were most likely confusing and even alienating. The nurse’s focus therefore was on his protocols and not on what Elizabeth might be experiencing as the patient. Similarly, having to re-ask her history, D1’s focus is on checking his facts anew with Elizabeth rather than before he gets to her. On the one hand, asking her again reminds him of her case details, but he does so by saying he has ‘probably forgotten half of it’. His requestioning puts an additional burden on Elizabeth, who has to answer the same questions once more, and signals poor continuity of care to her as D1 is not making links to earlier responses she has given.
Theoretical links
As noted earlier, talking is the quickest and most reliable way of communicating critical patient information in the ED, given the complexity of patients and the speed of care developments (Ayatollahi, Bath & Goodacre, 2013; Eisenberg et al., 2005; Manidis, 2013; Nugus, 2007). Work in the ED requires fast thinking, frequent checking, and constant vigilance by ED practitioners. ED models of care tend to be designed as though care consists of a staged and linear flow of activities (as envisaged in Figure 5.1).
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