Updated: Feb 27
You are working in the Emergency Department on a day when it is busy and bed blocked. You assess a patient presenting with chest pain in the EMS offload area. Standing next to the stretcher, stopping to move every time a porter comes by with another patient stretcher, you sense that your patient is frustrated. After the initial workup is complete, you go to reassess your patient and review the results. As you start explaining the findings, the patient interrupts and says, “I’ve been sitting here for four hours and haven’t heard from anyone. Before that, everyone asked me the same questions over and over and now you’re talking to me with some medical mumbo jumbo that I don’t understand. All I want to know is what’s wrong and no one is telling me!”
Effective communication between patients and health care providers is integral to providing patient-centered care and has been previously identified as a significant driver of the ED patient experience.(1) In our last post, we discussed how the environment of the Emergency Department (ED) can hamper communication between care teams in transitional periods. Many of the same challenges are present in communication with patients. It is important to recognize how both verbal and non-verbal communication may be optimized. This post will cover three topics surrounding patient communication in the ED. We will first discuss how effective communication can impact patient care. We will then discuss the barriers to effective communication with patients. Finally, we will outline some strategies to improve patient communication in the ED.
How Communication Impacts Patient Care
Effective communication in the ED between patients and care providers is required in every aspect of a clinical encounter. It is important to be mindful of both verbal content and tone in addition to body language, all of which may significantly influence a patient’s perception of care.(2) One study demonstrated that patients perceived the physician spent more time at the bedside when they were sitting instead of standing.(3)
In addition, effective communication has also been correlated with improved compliance and adherence to treatment.(4) Previous literature has conceptualized four critical stages where communication occurs in the ED.(5) These stages, as described by Engel et al, are:
Intake – when the patient first enters the ED
Assessment– when the patient is first assessed by the ED care team
Treatment– where the patient gets a general understanding of the diagnostic and treatment plan
Discharge– where the patient transitions back into the community
Recognizing these stages may be useful in identifying where communication can be improved. Looking at the discharge setting, for example, patients have commented that discharge sessions were too short, and/or did not provide an opportunity to ask questions.(6)
It should be mentioned that there is a well-documented association between patient satisfaction and communication. This was covered in a previous Emergency Medicine Cases podcast which is highly recommended to readers. Newer literature surrounding patient-reported outcome measures (PROMs) acknowledges that the measurement of specific areas of patient satisfaction represents novel methods of assessing quality outcomes in ED care.(7,8) PROMs will be discussed in-depth in a future post in the HiQUIPS series this year.
Barriers to Effective Patient Communication
The ED is an area which is particularly challenged with several communication barriers at the patient, provider, and environmental levels. Patients have varying levels of baseline health literacy and may present with various communication-limiting factors such as fear, anxiety, and pain. Additionally, gender, cultural and language issues may also be present. From a provider perspective, ED staff lack established rapport that comes with a longstanding relationship between a primary care provider and a patient. They are also are not offered much time to establish a meaningful rapport, and the time that they are able to spend with individual patients decreases as overall patient volumes increase. Furthermore, ED staff are often faced with interruptions as well as the pressure to concentrate on clinical aspects to avoid errors. Finally, In looking at the ED environment itself, crowding, staff shortages, and increasing patient volumes have been cited as communication barriers.(9,10)
Strategies to Improve Communication
Given the importance of communication in patient care, health care providers should actively work to optimize the methods in which they interact with patient. Simple interventions like sitting down may be used with great effect.3 Certain behaviours when interviewing patients have been shown to be associated with higher patient satisfaction score as well. These include acknowledging the wait-time with an apology, shaking a patient’s hand, overestimating the time expectations and beginning an encounter with “how can I help you?”(11) Use of shared-decision making tools may also prove to be useful.(12)
Seeing a chair in the room, you sit down and say “Mr. Johnson, I’m sorry about the delays that you’ve experienced today. I have the test results from before and wanted to discuss them with you. Before we continue, was there anything that you were particularly worried about today?” After discussing the results with the patient, you leave ample opportunity for the patient to ask additional questions.
Existing literature has demonstrated that the use of discharge leaflets may enhance overall communication.(13) It is generally recommended that written material is provided at no higher than a Grade 6 reading level in order to ensure maximum understanding for those with poor literacy or health literacy.(14) An excellent example of this comes from the patient passport at the Humber River Hospital. The use of patient information handouts could naturally extend to providing written discharge instructions to patients in order to augment their understanding of their discharge diagnosis.
Efforts to improve communication should not be done solely at the ED level. System-wide changes could also be used to promote the long term improvement of patient communication. Interventions which have been done to demonstrate this include a redesign of health team communication processes, as well as the utilization of dedicated educational curricula on communication.(15-17) Additionally, allowing patients to access their own electronic medical records and view visit notes may also strengthen communication.(18)
In summary, patient communication is a critical aspect of clinical care. Providers should prioritize improving communication in order to improve patient engagement, satisfaction, and adherence to treatment. A number of simple interventions could be performed to improve this ranging from behavioural modifications to providing information leaflets and written discharge instructions.
Stay tuned for our next post where we will introduce health informatics and its place within the Emergency Department.
Senior Editor: Rachel Sheps
Copyedited by: Paula Sneath
Sonis J, Aaronson E, Lee R, Philpotts L, White B. Emergency Department Patient Experience: A Systematic Review of the Literature. J Patient Exp. 2018;5(2):101-106. https://www.ncbi.nlm.nih.gov/pubmed/29978025.
Hermann R, Long E, Trotta R. Improving Patients’ Experiences Communicating With Nurses and Providers in the Emergency Department. J Emerg Nurs. January 2019. https://www.ncbi.nlm.nih.gov/pubmed/30655007.
Swayden K, Anderson K, Connelly L, Moran J, McMahon J, Arnold P. Effect of sitting vs. standing on perception of provider time at bedside: a pilot study. Patient Educ Couns. 2012;86(2):166-171. https://www.ncbi.nlm.nih.gov/pubmed/21719234.
Zolnierek K, Dimatteo M. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47(8):826-834. https://www.ncbi.nlm.nih.gov/pubmed/19584762.
Engel K, Buckley B, McCarthy D, Forth V, Adams J. Communication amidst chaos: Challenges to patient communication in the emergency department. Journal of Clinical Outcomes Management. 2010;17(10):17-21.
Mäkinen M, Castrén M, Huttunen K, et al. Assessing the discharge instructing in the emergency department: Patient perspective. Int Emerg Nurs. 2019;43:40-44. https://www.ncbi.nlm.nih.gov/pubmed/30316733.
Vaillancourt S, Seaton M, Schull M, et al. Patients’ Perspectives on Outcomes of Care After Discharge From the Emergency Department: A Qualitative Study. Ann Emerg Med. 2017;70(5):648-658.e2. https://www.ncbi.nlm.nih.gov/pubmed/28712607.
Vaillancourt S, Beaton D, Maybee A. Engaging patients to develop a patient-reported outcome measure for the emergency department. CMAJ. 2018;190(Suppl):S50-S52. https://www.ncbi.nlm.nih.gov/pubmed/30404856.
Knopp R, Rosenzweig S, Bernstein E, Totten V. Physician-patient communication in the emergency department, part 1. Acad Emerg Med. 1996;3(11):1065-1069. https://www.ncbi.nlm.nih.gov/pubmed/8922019.
Roh H, Park K. A Scoping Review: Communication Between Emergency Physicians and Patients in the Emergency Department. J Emerg Med. 2016;50(5):734-743. https://www.ncbi.nlm.nih.gov/pubmed/26818383.
Finefrock D, Patel S, Zodda D, et al. Patient-Centered Communication Behaviors That Correlate With Higher Patient Satisfaction Scores. Journal of Patient Experience. 2018;5(3):231-235. doi:10.1177/2374373517750414
Coronado-Vázquez V, Gómez-Salgado J, Cerezo-Espinosa de los Monteros J, García-Colinas MA. Shared Decision-Support Tools in Hospital Emergency Departments: A Systematic Review. Journal of Emergency Nursing. February 2019. doi:10.1016/j.jen.2019.01.002
Sustersic M, Tissot M, Tyrant J, et al. Impact of patient information leaflets on doctor–patient communication in the context of acute conditions: a prospective, controlled, before–after study in two French emergency departments. BMJ Open. 2019;9(2):e024184. doi:10.1136/bmjopen-2018-024184
Safeer R, Keenan J. Health literacy: the gap between physicians and patients. Am Fam Physician. 2005;72(3):463-468. https://www.ncbi.nlm.nih.gov/pubmed/16100861.
Aaronson E, White B, Black L, et al. Training to Improve Communication Quality: An Efficient Interdisciplinary Experience for Emergency Department Clinicians. Am J Med Qual. September 2018:1062860618799936. https://www.ncbi.nlm.nih.gov/pubmed/30235933.
Gunalda J, Hosmer K, Hartman N, et al. Satisfaction Academy: A Novel Residency Curriculum to Improve the Patient Experience in the Emergency Department. MedEdPORTAL. 2018;14:10737. https://www.ncbi.nlm.nih.gov/pubmed/30800937.
Opper K, Beiler J, Yakusheva O, Weiss M. Effects of Implementing a Health Team Communication Redesign on Hospital Readmissions Within 30 Days. Worldviews on Evidence‐Based Nursing. 2019;16(2):121-130. doi:10.1111/wvn.12350
Delbanco T, Walker J, Bell S, et al. Inviting patients to read their doctors’ notes: a quasi-experimental study and a look ahead. Ann Intern Med. 2012;157(7):461-470. https://www.ncbi.nlm.nih.gov/pubmed/23027317.