• Identification of barriers to effective communication, & application of different strategies/tools will enhance team performance and reduce morbidity/mortality

Communication failures are extremely common and are associated with inadvertent patient harm, including mortality, as the provision of care during emergencies is highly complex and is coupled with inherent human performance-related limitations, where even highly experienced clinicians make serious mistakes.

These observations were made in a continuing medical education-related lecture on ‘Communication in medical emergencies – A matter of life and death', which was delivered by H. Dharmakeerthi (Consultant Anaesthetist attached to the Colombo North Teaching Hospital, Ragama), and which was published in the Sri Lankan Journal of Anaesthesiology's 32nd Volume's Second Issue, this month.

The British poet Alexander Pope wrote that, “To err is human.”

Human error is defined by the Institute of Medicine (R.L. Sirota's ‘The IOM’s Report on Medical Error Implications for Pathology’) as, ‘either a failure of a planned action to be completed as intended, or the use of the wrong plan to achieve an aim’. Human error is inevitable, and everybody makes mistakes. This has been cited as a primary cause or contributing factor in disasters and accidents in industries as diverse as nuclear power. The evaluation of a series of aircraft accidents led to the start of formal training in human factors in the aviation industry through their crew resource management (CRM) programme (D. Munos-Marron's ‘Human factors in aviation: CRM’). Human error has been documented as the primary contributory factor in more than 70% of all major commercial aeroplane accidents, and the majority of these accidents were due to communication failures (S. Prineas, K. Mosier, C. Mirko, and S. Guicciardi's ‘Non-technical skills in healthcare. Chapter 30. Textbook of Patient Safety and Clinical Risk Management’).

Communication failures are the leading cause of inadvertent patient harm. The evaluation of incidents received by the Joint Commission for Hospital Accreditation has identified that communication failures were associated with more than 70% of the cases (M. Leonard, S. Graham, and D. Bonacum's ‘The human factor: The critical importance of effective teamwork and communication in providing safe care’). Communication is, as mentioned in ‘Human Factors in Patient Safety, Review of Topics and Tools. Report for the Methods and Measures Working Group of the World Health Organisation (WHO) Patient Safety’, the transfer of information, ideas, or feelings. Proper communication provides knowledge, establishes and maintains good relationships, improves awareness, minimises conflicts, and is vital for leadership and team based coordination. Every aspect of patient management requires effective communication between individuals, teams, and the organisation. So, the failure in communication is associated with the majority of human errors causing critical events. Every member of the team should excel in good communication techniques to prevent such mishaps. 

Delivery/receiving information

Thinking and preparation 

The transmission of information in a complex and dynamic environment is challenging. It is highly likely that even an experienced clinician may not be able to do it effectively. Having a clear idea of the information that one is transmitting will help one in presenting a well-structured message. Making a note of the relevant information according to a structured format, prior to making a call, is helpful in delivering the relevant information within a short period. The most widely used structured format is the situation, background, assessment, and recommendation (SBAR) format, which was initially developed by the United States Navy nuclear submarine industry, and later on was incorporated into the clinical practice. ‘Introduction’ can be added to the beginning to introduce both parties before delivering the message (ISBAR). The age, time of injury, mechanism, injuries, symptoms and signs, treatment (AT-MIST) format and allergies, medications, past medical history, last meal, events leading to the presentation (AMPLE) format are commonly used by the United Kingdom's ambulance services during their pre-alert calls and handovers, especially in acute trauma. 

A clinical example: 

Identify who you are, and whom you are speaking to (“Hi! I’m Dr. Susan, the Surgical Registrar, am I calling Dr. Brown, the Consultant Surgeon?”). 

Situation in brief (“I am calling about a bleeding poly-trauma patient in the Accident/Emergency”). 

Background/Past medical history? What happened up to now (“He is a 25-year-old gentleman with no significant past medical history. This has happened half an hour ago”).

Assessment – Findings on the assessment and what intervention has already been done? (“He is conscious and the airway is patent, and there is no obvious chest injury. He is pale and tachycardiac [the heart is beating much faster than normal, usually more than 100 beats per minute], and his blood pressure is 70/40 millimetres of mercury. Abdomen distended, and the face, arm, speech test [FAST] is positive. He has a 17 gauge cannula, and the second pint of normal saline is running fast. Massive transfusion protocol [MTP] is activated.”) 

Recommendation – What do you suggest or what should you do? (“Shall I take him to the theatre?”) 

Listening 

In any communication, listening is as equally important as talking. Listening is an essential component in two-way communication, such as face-to-face or telephone conversations. Supporting conversation, showing that you are engaged and willing to listen more, and giving full attention to what the person is saying enables a complete message to be delivered effectively. We can also ask some questions if any clarification is necessary. 

Speaking (specific/directed/acknowledged) 

Specific – Messages should be clear, precise (accurate), and concise (brief but comprehensive). All messages should be delivered using good voice projection at a normal pace. Use numbers rather than non-specific descriptions. For example, “His blood pressure is 80 by 40”, instead of “His blood pressure is low”, gives the exact values and the interpretation is easy to make clear decisions. The vocabulary (words and mnemonics) should be in ‘common language’, where everyone in the team should be able to understand them. For example, “George, the pneumothorax (a collection of air outside the lung, but within the pleural [a serous membrane that folds back on itself to form a two-layered membranous pleural sac] cavity) is on the left side. Right? I want you to do the finger thoracostomy (a procedure used to place a chest tube)”. The word ‘right’ should only be used to indicate the side (left or right), but not to indicate whether it is ‘ok’ or ‘correct’. In this example, the receiver may get confused about the side of the pneumothorax. If your message is about the administration of a medicine, the ‘five rights’ convention (patient, drug, time, dose, and route) should be followed. For example, “Smith, please give adrenaline one in thousand, point five millilitres (ml) intramuscular (IM) immediately to Mr. John”. Using mitigating language may also make the message less specific, and might result in confusion and not achieving it. For example, “Would you be able to intubate this patient?”, versus “Please intubate”. 

Directed – Use individual names to direct the message to a specific person. For example, “Can someone call the blood bank and activate the MTP?”, versus “Vicky, (staring at Vicky) please call the blood bank and activate the MTP”. 

Acknowledged – The delivery of the message may not be adequately received and apprehended in most circumstances. Even if it is received adequately, sometimes, the intended task may not be carried out due to various reasons. Once the message is delivered, repeating the content by the receiver (read back) may allow both parties to confirm that the information is received correctly (J.P. Brown's ‘Closing the communication loop: Using read back/hear back to support patient safety’). When the task is completed by the receiving party, it can also be communicated back to the team or team leader (closed loop communication). This tool of communication assists in minimising errors in critical environments. 

A clinical example –

George – “Smith, give a particular anti-fibrinolytic agent one gram (g) intravenous (IV) over 10 minutes.” Smith – “Do you want me to give one g of the specific anti-fibrinolytic agent IV over 10 minutes?” George – “Yes, please.” Smith – “I just started giving one g of the said anti-fibrinolytic agent as a slow injection.” 

Non-verbal communication 

Non-verbal communication is an effective and acceptable way of communication if appropriately used in emergencies. The use of body language, facial expressions, eye contact, body movements, gestures, and postures can be used to deliver some information in crises. For example, hand gestures to say ‘stop’ or ‘start’ and head nodding to say, ‘yes’ or ‘ok’.

Assertiveness

Assertiveness is the ‘quality of being confident and not frightened to say what you want or believe without being aggressive’. Lack of assertiveness has led to numerous disasters and critical events, including the world’s worst aeroplane accident in aviation history, and the Elaine Bromiley case in medicine. The ability to escalate one's concern appropriately without any reluctance improves patient safety, especially in hierarchical structures, where the team is comprised of more senior and junior members. Junior staff should be empowered by providing them with training in assertion-related techniques and minimising the hierarchical structure. The team leader should specifically make sure that the environment is safe and ‘friendly’ for the other members to speak up if there is any concern. This can be facilitated by frequently asking for their opinion or concerns whenever a decision is made. This kind of non-hierarchical structure allows even a junior nurse to raise her/his voice, if ‘something is not right’. Certain tools have been developed to escalate the concern if the authoritarian leader does not respond appropriately. The concern, uncomfortable, unsafe (CUS) tool was initially developed by the United Airlines and now it is frequently being used in medicine.

A clinical example – 

C – “His saturation is dropping. I’m concerned about it.”

U – “His airway doesn’t look patent, and he has obstructed breathing. I am uncomfortable with the situation.”

S – “I think he’ll go into cardiac arrest. This is unsafe. He needs immediate intubation.”

S – “Please stop and listen to me. I’m going to inform the consultant.”

Another aviation-based tool is probe or observation, alert, challenge, emergency (PACE) tool. It follows a similar structure as in the CUS tool. The shared mental model involves having a similar situational awareness. Communication improves the situational awareness among team members.

Team leaders should always try and make sure that the team is aware of what has already been done, what is the current status, and what is going to happen. This can be achieved by various techniques.

Pre-briefing or briefing 

Discussing the patient’s condition based on the information received through the alert call, and planning the immediate management before the arrival of the patient, spending a few minutes prior to the start of the shift or before patient arrival, gives the team the sense of near-field situational awareness. It in turn reduces anxiety, gives an opportunity to add inputs, and finally, improves performance. The WHO Surgical Safety Checklist is another form of well-accepted briefing tool used before a surgical procedure. 

Holding intermittent briefs (‘time-outs’) during patient management helps improve situational awareness and the shared mental model. Usually, the team leader pauses and updates on the condition, and plans the management with the team. Advanced trauma life support (ATLS) recommends time-outs in two, five, and 10 minutes into the patient management (the American College of Surgeons' ATLS, Student Course Manual. 10th edition).

Verbalising what is going through the team leader’s mind (‘thinking aloud’) when he/she analyses and makes decisions, also improves awareness.

Proper handovers (handoffs) to the other teams will also enhance the shared mental model (P.M. Jones, R.A. Cherry, B.N. Allen, K.M.B. Jenkyn, S.Z. Shariff, S. Flier, K.N. Vogt, and D.N. Wijeysundera's ‘Association between handover of anaesthesia care and adverse post-operative outcomes among patients undergoing major surgery’). 

Debriefing is usually performed immediately, or as soon as possible after the patient management is over (when the events are fresh), in order to reflect on the performance. This is a good opportunity for the team to evaluate their management, and learn from the experience. Then, the team can discuss the strategies to overcome the problems next time.

Identifying barriers to communication

Communication is not complete unless one recognises barriers and overcomes them appropriately.

The ‘lack of communication’, or the ‘failure to communicate’ is recognised as one of the most significant barriers (O.T. Guttman, E.H. Lazzara, J.R. Keebler, K.L.W. Webster, L.M. Gisick, and A.L. Baker's ‘Dissecting communication barriers in healthcare: A path to enhancing communication resiliency, reliability, and patient safety’). The main reason for this is the ‘psychologically unsafe’ environment. This prevents the members from ‘speaking up’-based behaviour. If the team member had previous experience of being ignored, humiliated, confronted, intimidated, or any other bad consequence by speaking up, there is a higher chance of being quiet the next time. 

Sometimes, team members do not speak up for the fear of being wrong, being not prepared, or being perceived as incompetent. In certain circumstances, junior or less experienced members might think that encroaching into someone’s area of expertise should not be done. Trainees under the direct supervision of a senior member may feel that speaking up might introduce confrontation, which might badly affect their assessment. Strategies to improve speaking up-related behaviour are to create an environment where these barriers are minimal, and to empower the team members to raise their concerns without being afraid of the consequences (the CUS tool). Sometimes, certain organisational failures (system failure), such as the non-availability of necessary channels for communication, the non-functioning of existing channels or not using them (trauma alert call or crash call facility) may be accountable for the lack of communication.

Limitations in the cognitive function of an individual will affect the acquisition, manipulation, and reasoning of data, which in turn can adversely affect effective communication. Human cognition is highly vulnerable to being influenced by interruptions and distractions, such as background noises, human traffic, sudden changes in the situation, cross talking, the use of smartphones, and unnecessary interruption to a conversational flow. Hunger, dehydration, the lack of sleep, and fatigue may also increase the risk of cognitive dysfunction. The ‘sterile cockpit rule’, used in flight operations, where all non-essential activities are stopped during critical phases of flying (taxing, take off, landing, and any other operations conducted below 10,000 feet, per R. Fuzier, P. Izard, E. Petiot, and F. Jaulin's ‘Safety in healthcare: From the flight deck to the operating room’) has been successfully incorporated in medicine, in which only essential activities are performed during certain critical phases of patient management (handovers, induction and recovery from anaesthesia, and complex surgery). Another example of this is the ‘hands off, eyes on’ rule for 60 seconds to facilitate the handover of patients from the ambulance crew on arrival to the emergency department (S. Jefferys, D. Maxwell, D. Fitzpatrick, and J.P. Loughrey's ‘Handover: Skills to enhancing the pre-hospital emergency medicine – emergency medicine [PHEM-EM] interface’). Language (linguistic) barriers are very common. The communication style, whether it is submissive (trying to please the other party to avoid conflicts), or aggressive (expressing the message with a demanding, commanding, authoritative, or blaming nature) can influence effective communication. Tone (variations in amplitude), and tempo (speed of flow) can also affect communication to varying degrees. Non-standard or less familiar words should not be used. Certain specialties may not understand some words commonly used in another (‘for the induction, I used fentanyl’). Sometimes, words with similar sounds (‘abduct vs. adduct’, ‘decrease vs. increase’) may confuse the receiver. The best strategy to overcome most of the linguistic barriers is to use the ‘read back’ and closed loop communication.

Physical barriers, such as personal protective equipment (PPE), face masks, screens, distance, and wearing protective glasses directly affect non-verbal and verbal communication. Hearing impairment, signal interruptions, and problems in understanding the language are obvious reasons for communication failures.

Adequate knowledge of frequent communication errors, the identification of barriers to effective communication, and the application of different strategies and tools will enhance team performance and reduce morbidity and mortality.