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Original article
1
Emergency Department,
Bristol Royal Infirmary, Bristol,
UK; 2 Imperial College
Healthcare NHS Trust,
London, UK; 3 Clinical
Research Safety Unit, London,
UK
Correspondence to:
Dr E Redfern, Emergency
Medicine, Bristol Royal Infirmary,
Marlborough Street, Bristol
BS2 8HW, UK; emredfern@
hotmail.com
Accepted 16 January 2009
658
Improving communication in the emergency
department
E Redfern,1 R Brown,2 C A Vincent3
ABSTRACT
Background: A previous study examined the commu-
nication process within the emergency department (ED)
and identified a complex process with many opportunities
for breakdown and error. In this paper the first two
interventions in a series of studies to improve this highly
vulnerable communication process are described.
Aim: To improve the reliability of two steps of the
communication process identified as having a high
probability of failure: (1) transfer of information between
the ambulance crew and the emergency staff; and (2)
preparation of written documentation following patient
assessment.
Methods: Quantitative assessments of the reliability of
communication were carried out to establish the extent of
problems highlighted during the failures modes and
effects analysis (FMEA) previously described.
Improvements to the process were then introduced, and
the process re-examined to assess the impact of the
changes and reduction of the likelihood and severity of the
failure mode.
Results: The studies demonstrated very high levels of
communication failure, particularly in transfer of written
information from the ambulance crew. Countermeasures
were introduced which resulted in a substantial reduction
in missing and incorrect information. In addition, there
was a threefold improvement in the number of correct
clinical documents used by doctors in the resuscitation
room.
Conclusion: Observational study and audit revealed the
extent of process failures identified in the initial FMEA
process. With the introduction of simple changes to the
communication system, a marked improvement in the
availability and quality of pertinent clinical information was
achieved with considerable implications for the timeliness
and quality of care provided to patients.
The communication process in the emergency
department (ED) is complex, and a number of
studies have described problems and breakdowns
in communication with significant implications for
patient care.1–3 In an earlier paper we reported a
systematic mapping and analysis of the commu-
nication process using Failure Modes and Effects
Analysis (FMEA) which identified a considerable
number of vulnerabilities and potential for failure.4
The communication process proved to be unduly
complex and there were many opportunities for
error which may impact on patient care.
Based on the results from the FMEA, we are now
engaged in a series of studies aimed at improving
the communication at points in the pathway
where significant vulnerabilities were identified.
In this paper we report findings from the first two
interventions, which form part of a larger project
on quality improvement in the ED. We focused on
the Patient Report Form (PRF) provided by
ambulance crews and the standard printed docu-
ment produced for the recording of clinical
information by the doctor. Both of these steps
had been identified by staff as having significant
problems with potential impact on patient care.
Our findings were in accord with those of the few
previous studies in this area. Previous research on
handover from ambulance providers to ED staff
has uncovered gaps in communication,2 with one
study showing that only 56% of verbal informa-
tion is accurately retained by the ED staff.5 The
perceived quality of verbal handover has been
shown to be variable between different ambulance
crews.6
STUDY 1: IMPROVING TRANSFER OF
INFORMATION FROM THE PATIENT REPORT FORM
(PRF)
The PRF is the written record detailing the events
from initial call to ambulance control, arrival of the
ambulance crew at the scene and transfer to
hospital. It is completed by ambulance crews and
records basic details such as unique crew identifica-
tion numbers, exact times relating to movements
of the ambulance both at the scene and arrival at
hospital, as well as patient demographic details.
Clinical data recorded include the reason for the
call out, medication and allergies, as well as the
patient’s clinical condition, vital signs and drugs
given. Comments on the condition of the patient
may also be included, particularly any signs of
deterioration or improvement.
The PRF ideally serves to support the efficient
transfer of care to the next healthcare professional
involved with the patient. The details recorded are
particularly crucial if the patient is not able to
communicate effectively or where the only infor-
mation available comes from bystanders who
witnessed the incident leading to the ambulance
call. Clinical staff working in the ED consider the
PRF information as absolutely vital in these
circumstances and as highly informative at other
times; however, accessing this vital information
can be problematic.
The PRF used in our region (London) is a carbon
copy triplicate. The top two copies are retained by
the ambulance trust for legal and audit purposes.
The bottom copy is handed to personnel in the ED.
After arriving in the ED, the ambulance crew give a
brief verbal handover to the nurse receiving the
patient. The crew then pass the demographic
details of the patient to an ED receptionist who
registers the patient onto the computer system. If
the patient has attended the ED previously and the
Emerg Med J 2009;26:658–661. doi:10.1136/emj.2008.065623
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Table 1 Failure modes in the transfer of information from ambulance crews
Process Failure mode
Patient report form Missing in real time
Hard copy barely legible
Scanned copy illegible
correct demographic details are entered, the records will be
matched and linked up to previous episodes. A set of ED notes is
then generated for the patient and the bottom copy of the PRF
is scanned and attached electronically to the patient’s current
episode. This enables the attending clinician to view the PRF
along with copies of written documentation from previous
attendances.
In practice, however, both clinical reports and the formal
FMEA process identified a number of problems with this
apparently straightforward process. The PRF might be missing
or illegible in varying degrees, completely nullifying the
ambulance crew’s efforts to communicate effectively with
emergency staff (table 1). We therefore designed and carried
out a quality improvement study with the following aims:
c To establish the usefulness of the information on the PRF to
clinical care.
c To quantify the number of missing or illegible scanned
images.
c To develop and evaluate an intervention to resolve any
problems identified.
Method
Design and setting
The study was set in a busy central London ED. We first
assessed the quality and clinical value of written information
provided by ambulance crews. We then assessed measured
communication efficiency before and after an intervention to
improve availability of information from the PRF.
Procedure and measures
The first stage was to assess the information available from the
PRF. In this phase all paper copies of PRFs submitted by the
ambulance crews during a single week (n = 182) were collected
and analysed. The standard of completion of the information
and usefulness to clinical care was analysed by the principal
author (ER). The presence or absence of the following patient
information was assessed:
c Usefulness of information regarding the presenting com-
plaint.
c Presence of abnormal and normal observations.
c Medication given by ambulance crews.
c Information about patient’s normal medication.
c Information about allergies.
Table 2 Legibility of Patient Report Form before and after intervention
Pre-
intervention Sample size
Wholly legible 0 250
Partially legible 205 250
Wholly illegible 45 250
Scanned to 175 250
database
Emerg Med J 2009;26:658–661. doi:10.1136/emj.2008.065623
Original article
Cause Effect
Not handed in by ambulance crew Wealth of clinical information lost
Misplaced by ED team
Third copy in a pack of carbon paper Unable to access important information
Very faint writing Unable to access important information
Following this, the reliability of the communication process
was examined and quantified. A total of 250 sets of notes of
patients brought in by ambulance were retrospectively audited
to examine: (1) the presence or absence of the PRF in the notes
and (2) the degree of legibility of the scanned copy. Following
the intervention, a further 250 sets of notes were examined for
the same factors.
Intervention
We approached members of the team seeking ideas about how
to improve the legibility of the scanned document. We then
discussed the feasibility of implementing the change to the
system with our reception staff. A simple solution was to
photocopy the top sheet of the PRF at the time of the crew
arriving in reception and then to scan the photocopied
document: this resulted in a totally legible electronic copy
available to the departmental staff during the patient atten-
dance. In addition, the receptionists undertook to actively ask
the ambulance staff for the PRF in order to reduce the number
of PRFs that were not transferred. The reception staff agreed to
a trial of this system for 1 month. Emails were sent out to every
receptionist, the change in practice was discussed at the
monthly staff meeting, posters were made and the changes
were discussed with the ambulance service.
Results
Clinical value of patient report form (PRF)
The initial assessment of the PRF sheets showed that they
contained substantial amounts of important clinical informa-
tion that was often essential to proper care of the patient. Of
the 182 PRF sheets examined: 100% (182/182) contained useful
details regarding the presenting complaint; 55% (100/182) of the
documents detailed abnormal observations; 15% (28 of 182)
recorded medication given by the ambulance crew; 66% (122/
182) of the PRFs documented the patient’s own medication; and
88% (160/182) noted allergies or the absence of allergies.
Intervention to improve transfer of information
The simple interventions produced a dramatic improvement in
the information available to ED staff. Before the intervention 82%
of the scanned PRFs were completely illegible and 18% partially
legible; after the intervention, 100% were wholly legible (table 2).
The numbers of PRFs that were scanned to the database improved
from 70% to 80%. The two-sample proportion z test was used to
Post- Difference in
intervention Sample size z Statistic proportions, %
250 250 222.36 (p,0.01) 100 (p,0.01)
0 250 18.64 (p,0.05) 82 (p,0.01)
0 250 7.03 (p,0.01) 18 (p,0.01)
200 250 22.58 (p,0.01) 10 (p,0.01)
659
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Original article
Table 3 Use of correct template before and after the intervention
Notes recorded on correct template
Pre-intervention Post-intervention z Value
Majors 86% (43/50) 90% (45/50) 20.615
Minors 66% (33/50) 77% (38/50) 21.102
Major trauma 15% (3/20) 45% (9/20) 22.070 (p,0.05)
Cardiac arrest 10% (2/20) 35% (7/20) 21.893
Total 58% (81/140) 71% (99/140) 22.245 (p,0.05)
analyse the results, which were both clinically and statistically
significant.
STUDY 2: GENERATION OF CORRECT NOTE FORMAT FOR
DOCTORS
The second study followed a similar pattern, examining another
issue highlighted by the FMEA process concerning documenta-
tion used by doctors to record clinical information for different
types of patient. In our ED, proforma style structured notes are
used to record, structure and guide the collection of clinical
information. The department uses five different types of
proforma, two generic that are used in either majors area
(trolley assessment) or in minors area (ambulatory care). These
two are printed out automatically at registration according to
the area of the department to which the patient is directed. The
remaining three are specifically designed for critically ill patients
and include separate ones for cardiac arrest, serious illness and
major trauma. These are printed by the receptionists on arrival
of the patient according to their predominant complaint. The
findings of the FMEA suggested that there was a high
probability of the wrong document being requested or the
wrong document being generated, leading to a delay and
inappropriate direction of patients within the department. The
immediate effects of this on patient care are that: (1) it is
difficult to record vital information; (2) much time is wasted
reading through notes to identify salient information; and (3) a
proper management plan may not be recorded. We therefore
carried out a further quality improvement study to (1) establish
and quantify whether the correct documents were being
generated for each patient and whether each set of notes
contained a management plan; and (2) evaluate the impact of
an intervention to improve this aspect of documentation.
Method
Design and setting
The study was set in a busy central London ED. We measured
the efficiency of the communication using the proforma notes
before and after an intervention designed to ensure the correct
document was generated.
Procedure and measures
A retrospective audit of 160 ED notes was carried out to assess
whether the correct template was used for the correct
presenting complaint and whether there was a clear manage-
ment plan recorded in the notes, regardless of the proforma
used. Patients were identified by searching within the term
‘‘area = majors/minors’’ or ‘‘presenting complaint = trauma/
cardiac arrest’’ on SYMPHONY database. Fifty sets of majors
and minors notes were studied and 20 each of the major trauma
and cardiac arrest notes in relevant patients. Following the
intervention, a further set of 160 notes were audited in the same
way.
660
Table 4 Documentation of management plan before and after the
intervention
Notes documented with management
plan
Pre-intervention Post-intervention z Value
Majors 60% (30/50) 88% (44/50) 23.192 (p,0.01)
Minors 91% (46/50) 91% (46/50) 0
Major trauma 60% (12/20) 90% (18/20) 22.191 (p,0.05)
Cardiac arrest 0% (0/20) 0% (0/20) 0
Total 63% (88/140) 77% (108/140) 22.609 (p,0.05)
Intervention to improve information transfer and documentation
Staff members were invited to make suggestions on how to
improve the generation and use of the correct documents.
Solutions generally focused on raising awareness of the different
documents among the reception and medical staff at teaching
and staff meetings. The importance of documenting a manage-
ment plan was discussed with the medical staff after presenta-
tion of the initial findings of the audit. We also made another
simple but crucial change by placing an electronic copy of each
one of the cardiac arrest and major trauma templates on the
computers in the resuscitation room. This meant that the
correct document could be printed even if an incorrect
document had initially been generated.
Results
The initial data collection confirmed the problems identified in
the FMEA; use of the correct template ranged from 86% for
majors to only 10% for patients with cardiac arrest. Only 60%
of patients with serious conditions had a documented manage-
ment plan. Again, the two-sample proportion z test was used to
analyse the results, and the intervention produced both
clinically and statistically significant improvements (tables 3
and 4).
DISCUSSION
Both the FMEA and the studies to quantify the extent of the
problems identified serious weaknesses and inefficiencies in the
system of communication with the ED. We fully expect that,
when further quantitative studies are carried out on different
points in the process, we will see further evidence of routine
failure and further opportunities for improvement.
However, simple interventions produced significant results.
Clinical staff now have improved timely access to relevant
information from ambulance crews, the correct template is
more frequently being used and documentation of management
plans has increased. The process will be audited to judge the
longevity of the change once the intervention has become
established, but it is possible that there will be a reduction in the
benefit seen unless there is some continued feedback and
monitoring of the system. Involving staff in all aspects of
diagnosis and management of the problems with communica-
tion will hopefully ensure that the team understands why
changes to the system need to be made.
Solutions to problems need to be time- and resource-neutral
or to require little additional effort. Hospital and ambulance
staff have seen the benefit of accessibility and judge that the
small amount of time taken to copy the PRF is worth the effort.
The solution offered for the legibility and retention of the
document gave an unexpected benefit of having the PRF
available at the point of contact with the patient rather than
as a loose copy that is somewhere in the department.
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Looking further ahead, we hope that information technology
will bring further improvements to communication systems.
The ambulance service is working towards integration of a
prehospital electronic patient record with the hospital record
and with the National Care record service, but this technology
will not be available until 2013. Electronic patient record
systems offer solutions for printing documents according to
logic modules or rules in the system. However, the system still
relies on humans entering data to drive the rules, and that is
prone to error. The electronic patient record will require
structured data entry, and early adoption of this approach—
albeit on paper—allows evaluation of the structure and best
way to present data.
The findings of this study have several implications for future
practice. First, EDs may be able to use this methodology to
examine prospectively their own areas of potential systems
failure and improve the design of their care process; the complex
issue of communication can be simplified using a formal
technique. Second, involving staff in the study drew on their
knowledge, experience and creativity, generated many good
suggestions and ensured acceptance of the eventual implemen-
tation. Third, it shows that making simple changes, when
introduced and evaluated systematically, can lead to large
improvements in the care provided to patients.
CONCLUSION
We conclude these two papers with a final reflection. What took
us so long? Clinical staff had been using a highly inefficient and
frustrating system producing illegible transfer forms for years,
yet no action had been taken. We believe that this is a common
experience throughout health care, both in the UK and in other
countries. Many reasons might be advanced for this, with
varying degrees of criticism of healthcare staff, but three
particular issues emerge. The first is the extraordinary tolerance
of healthcare staff for inefficient and failure-prone systems and
the degree to which they cope with frustrating working
conditions rather than attempting to change them. Secondly, it
Emergency Medicine in the Developing World
Cape Town, 23–26 November 2009
The Emergency Medicine Society of South Africa (EMSSA) is delighted to announce the second
Emergency Medicine in the Developing World conference. All aspects of emergency care will be
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Further details: http://EMSSA2009.co.za or contact Belinda Chapman (belinda.chapman@uct.ac.za)
Emerg Med J 2009;26:658–661. doi:10.1136/emj.2008.065623
Original article
took a formal study to bring home the full extent of the
problems; even though we are very familiar with the environ-
ment, we did not fully appreciate the complexity of the
communication process or the extent of the failures. Finally,
dedicated time is needed even to bring about simple, if far
reaching, changes. When a clinical member of staff was allowed
sufficient dedicated time to assess and improve the system,
substantial gains were made in a relatively short time. We believe
that there is a more general lesson here. We will, in the end,
provide better care for our patients if we begin to allocate some
proportion of clinical time to system improvement rather than
direct patient care. This has already happened to some extent
with the requirement to carry out audit, but we need to go
further in both allocating more time and being more ambitious,
not simply auditing but actually effecting improvement.
Acknowledgements: The authors thank Dr Robert Redfern for help with the
statistical analysis in this paper.
Funding: The Clinical Safety Research Unit is affiliated with the Centre for Patient
Safety and Service Quality at Imperial College Healthcare NHS Trust which is funded
by the National Institute of Health Research. This research described here was
supported by the National Institute of Health Research.
Competing interests: None.
Provenance and peer review: Not commissioned; externally peer reviewed.
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Improving communication in the emergency

department
E Redfern, R Brown and C A Vincent

Emerg Med J 2009 26: 658-661

doi: 10.1136/emj.2008.065623

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