Network analysis of team communication in a busy emergency department

Knowing your team in the intensive care unit: an ethnographic study on familiarity

Effective interprofessional team function is integral to high-quality care in the intensive care unit (ICU). However, little is known about how familiarity develops among teams, which may be an important antecedent to effective team function and quality care. To examine team familiarity and how it impacts ICU team function and care, we conducted an ethnographic study in four ICUs (two medical ICUs, one mixed medical-surgical ICU, and one surgical ICU) in two community hospitals and one academic medical center. We conducted 57.5 h of observation, 26 shadowing experiences, and 26 interviews across the four ICUs sequentially. We used thematic analysis to examine familiarity among the team. We found that ICU team members become familiar with their team through interpersonal, relational interactions, which involved communication, time working together, social interactions, trust, and respect. Our findings underscore the relational aspect of effective teams and demonstrate that time working together, social interactions, communication, developing trust, and respect are pathways to familiarity and optimal team function. Leveraging unique and creative ways to enhance the relational aspects of ICU teams could be an area for future research and lead to improved ICU outcomes.

Strategies to Measure and Improve Emergency Department Performance: A Review

Emergency Departments (EDs) globally face escalating challenges such as overcrowding, resource limitations, and increased patient demand. This study aims to identify and analyze strategies to enhance the structural performance of EDs, with a focus on reducing overcrowding, optimizing resource allocation, and improving patient outcomes. Through a comprehensive review of the literature and observational studies, the research highlights the effectiveness of various approaches, including triage optimization, dynamic staffing, technological integration, and strategic resource management. Key findings indicate that tailored strategies, such as implementing advanced triage protocols and leveraging telemedicine, can significantly reduce wait times and enhance patient throughput. Furthermore, evidence suggests that dynamic staffing models and the integration of cutting-edge diagnostic tools contribute to operational efficiency and improved quality of care. These strategies, when combined, offer a multifaceted solution to the complex challenges faced by EDs, promising better patient care and satisfaction. The study underscores the need for a comprehensive approach, incorporating both organizational and technological innovations, to address the evolving needs of emergency healthcare.

Team situational awareness in the context of hospital emergency: A concept analysis

BACKGROUND

Successful management of in-hospital life threatening and emergency conditions require a well working, collaborative team. One of the vital skills that enhance team coordination of information and actions is team situational awareness (TSA). Although the concept of TSA has been long known in military and aviation settings, the concept has not been well investigated in the hospital emergency context.

OBJECTIVE

This analysis was to explore the concept of "TSA" in the context of hospital emergency to explain its meaning for optimum understanding and use in clinical practice and future research.

RESULTS

TSA encompasses two types of situational awareness, each equally important: complementary (individual) and shared situational awareness (SA). The three defining attributes of complementary SA are the perception, comprehension, and projection, meanwhile, the three defining attributes of shared SA include: (1) information is clearly shared; (2) interpreted in the same way; and (3) the same projection of actions formed to guide expectation. Although, TSA is related to other terms in literature, there is increasing acknowledgment that the concept has an impact on team performance. Finally, the two types of TSA should be considered when assessing team performance CONCLUSION: TSA is acknowledged in different fields requiring human control as a significant construct for team performance. Yet it needs to be examined in the emergency hospital context, systematically investigated and agreeably recognized as a fundamental factor in team performance.

Network approaches and interventions in healthcare settings: A systematic scoping review

INTRODUCTION

The growing interest in networks of interactions is sustained by the conviction that they can be leveraged to improve the quality and efficiency of healthcare delivery systems. Evidence in support of this conviction, however, is mostly based on descriptive studies. Systematic evaluation of the outcomes of network interventions in healthcare settings is still wanting. Despite the proliferation of studies based on Social Network Analysis (SNA) tools and techniques, we still know little about how intervention programs aimed at altering existing patterns of social interaction among healthcare providers affect the quality of service delivery. We update and extend prior reviews by providing a comprehensive assessment of available evidence.

METHODS AND FINDINGS

We searched eight databases to identify papers using SNA in healthcare settings published between 1st January 2010 and 1st May 2022. We followed Chambers et al.'s (2012) approach, using a Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. We distinguished between studies relying on SNA as part of an intervention program, and studies using SNA for descriptive purposes only. We further distinguished studies recommending a possible SNA-based intervention. We restricted our focus on SNA performed on networks among healthcare professionals (e.g., doctors, nurses, etc.) in any healthcare setting (e.g., hospitals, primary care, etc.). Our final review included 102 papers. The majority of the papers used SNA for descriptive purposes only. Only four studies adopted SNA as an intervention tool, and measured outcome variables.

CONCLUSIONS

We found little evidence for SNA-based intervention programs in healthcare settings. We discuss the reasons and challenges, and identify the main component elements of a network intervention plan. Future research should seek to evaluate the long-term role of SNA in changing practices, policies and behaviors, and provide evidence of how these changes affect patients and the quality of service delivery.

Quantifying care delivery team influences on the hospitalization outcomes of patients with multimorbidity: Implications for clinical informatics

The primary objective was to quantify the influences of care delivery teams on the outcomes of patients with multimorbidity. Electronic medical record data on 68,883 patient care encounters (i.e., 54,664 patients) were extracted from the Arkansas Clinical Data Repository. Social network analysis assessed the minimum care team size associated with improved care outcomes (i.e., hospitalizations, days between hospitalizations, and cost) of patients with multimorbidity. Binomial logistic regression further assessed the influence of the presence of seven specific clinical roles. When compared to patients without multimorbidity, patients with multimorbidity had a higher mean age (i.e., 47.49 v. 40.61), a higher mean dollar amount of cost per encounter (i.e., $3,068 v. $2,449), a higher number of hospitalizations (i.e., 25 v. 4), and a higher number of clinicians engaged in their care (i.e., 139,391 v. 7,514). Greater network density in care teams (i.e., any combination of two or more Physicians, Residents, Nurse Practitioners, Registered Nurses, or Care Managers) was associated with a 46-98% decreased odds of having a high number of hospitalizations. Greater network density (i.e., any combination of two or more Residents or Registered Nurses) was associated with 11-13% increased odds of having a high cost encounter. Greater network density was not significantly associated with having a high number of days between hospitalizations. Analyzing the social networks of care teams may fuel computational tools that better monitor and visualize real-time hospitalization risk and care cost that are germane to care delivery.

The impact of power on health care team performance and patient safety: a review of the literature

Communication failure within health care teams is a major cause of patient harm across health care settings. Factors which contribute to communication failure include actual or perceived 'power'. Whilst a great deal of ergonomics research has focussed on teamwork in health care, the role of power in relation to measurable patient safety and performance outcomes remains relatively unknown. This article presents the findings from a review of the literature on power within multidisciplinary health care team settings. Following a systematic literature search, nineteen studies were evaluated in terms of research design, methods and analyses across the included studies. The main impacts resulting from power imbalances include negative effects on team collaboration, decision-making, communication and overall performance. Wider patient safety research, and more specifically the ergonomics discipline, is encouraged to address the complex interplay between power and teamwork in the health care sector.Practitioner Statement: We conducted a review of studies focussed on the influence of power on teamwork in health care. The findings show that power can have negative impacts on collaboration, decision-making, communication, and team performance. We conclude that power represents an important area for ergonomics, both in health care and other settings.Abbreviations: CRM: crew resource management; TEM: threat and error management; SNA: social network analysis; EAST: event analysis of systemic teamwork.

A network analysis of patient referrals in two district health systems in Tanzania

Patient referral systems are fragile and overlooked components of the health system in Tanzania. Our study aims at exploring patient referral networks in two rural districts in Tanzania, Kilolo and Msalala. Firstly, we ask whether secondary-level facilities act as gatekeepers, mediating referrals from primary- to tertiary-level facilities. Secondly, we explore the facility and network-level determinants of patient referrals focusing on treatment of childhood illnesses and non-communicable diseases. We use data collected across all public health facilities in the districts in 2018. To study gatekeeping, we employ descriptive network analysis tools. To explore the determinants of referrals, we use exponential random graph models. In Kilolo, we find a disproportionate share of patients referred directly to the largest hospital due to geographical proximity. In Msalala, small and specialized secondary-level facilities seem to attract more patients. Overall, the results call for policies to increase referrals to secondary facilities avoiding expensive referrals to hospitals, improving timeliness of care and reducing travel-related financial burden for households.

Visual mapping of team dynamics and communication patterns on surgical ward rounds: an ethnographic study

BACKGROUND

The effect of team dynamics on infection management and antimicrobial stewardship (AMS) behaviours is not well understood. Using innovative visual mapping, alongside traditional qualitative methods, we studied how surgical team dynamics and communication patterns influence infection-related decision making.

MATERIALS/METHODS

Between May and November 2019, data were gathered through direct observations of ward rounds and face-to-face interviews with ward round participants in three high infection risk surgical specialties at a tertiary hospital in South Africa. Sociograms, a visual mapping method, mapped content and flow of communication and the social links between participants. Data were analysed using a grounded theory approach.

RESULTS

Data were gathered from 70 hours of ward round observations, including 1024 individual patient discussions, 60 sociograms and face-to-face interviews with 61 healthcare professionals. AMS and infection-related discussions on ward rounds vary across specialties and are affected by the content and structure of the clinical update provided, consultant leadership styles and competing priorities at the bedside. Registrars and consultants dominate the discussions, limiting the input of other team members with recognised roles in AMS and infection management. Team hierarchies also manifest where staff position themselves, and this influences their contribution to active participation in patient care. Leadership styles affect ward-round dynamics, determining whether nurses and patients are actively engaged in discussions on infection management and antibiotic therapy and whether actions are assigned to identified persons.

CONCLUSIONS

The surgical bedside ward round remains a medium of communication between registrars and consultants, with little interaction with the patient or other healthcare professionals. A team-focused and inclusive approach could result in more effective decision making about infection management and AMS.

Perception of Patient Safety Culture in the Framework of the Psychosocial Care Network in Western Amazon: A Cross-Sectional Study

The culture of patient safety should be considered a guiding principle for different areas of health. This research presents the results of an analysis on Patient Safety Culture (PSC), according to the perception of health professionals who work in the Psychosocial Care Network, through a descriptive observational cross-sectional study, using the Hospital Survey on Patient Safety Culture in a municipality in the Western Amazon of Brazil. Sixty-nine (69) professionals expressed that the best dimensions evaluated were: “expectations and actions to promote the safety of supervisors and managers” (75%) and “support from hospital management to patient safety” (64%). The worst evaluations were: “non-punitive responses to errors” (27%) and “general perceptions about patient safety” (35%), demonstrating that there still is a culture of fear of causing harm and the need for educational actions on patient safety. In general, all professionals have close contact with patients, regardless of the length on duty; however, the weekly workload and turnover in this sector is leading to a greater chance of errors. The analysis of the internal reliability of the dimensions ranged from 0.12 to 0.89. Only one-third of the respondents scored PSC as “Good” in the studied institutions and 63 out 69 professionals did not report any adverse events in the last 12 months. There are weaknesses in the observed perception of PSC and the obtained results show opportunities and challenges for improvements in the study system.

General phenomenon and communication experience of physician and nurse in night shift communication: A qualitative study

AIM

This paper explored the general phenomenon and psychological experience of the special background communication in night shift medical staff and provides better reference for night shift communication between doctors and nurses.

BACKGROUND

Physician-nurse communication has always been an important agenda for health care work and an important concept in nursing theory. During night shifts, effective doctor and nurse communication can enhance mutual trust, provide timely and appropriate medical services to patients, reduce adverse events and enhance patient safety.

DESIGN

A qualitative study was conducted.

METHODS

Husserl's descriptive phenomenology method and semi-structured in-depth interviews were used to collect data from 8 nurses and 5 doctors. Colaizzi's method was used to analyse data using MAXQDA 12. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was followed (see Appendix S1).

RESULTS

Three themes were extracted after sorting out and refining: the need to achieve goals in night-time physician-nurse communication; obstacles in night-time physician-nurse communication; and relationship culture in night-time physician-nurse communication.

CONCLUSION

Attention should be paid to the particularity of night shift and efficiency of achieving the goal of communication between doctors and nurses on night shift, and the hidden obstacles behind communication between doctors and nurses. Managers should pay attention to the cultural construction of night shift communication in the system, form a good night shift communication process and regularly train doctors' and nurses' related communication skills. And they should also study relationship culture rationally to improve the communication efficiency of night shift.

IMPLICATIONS FOR NURSING MANAGEMENT

The experiences described in this study contribute to a better understanding of obstacles hidden behind night shift physician-nurse communication. This also provides valuable information to professional managers who develop good doctor-nurse relationship culture.

Data-driven modeling of diabetes care teams using social network analysis

OBJECTIVE

We assess working relationships and collaborations within and between diabetes health care provider teams using social network analysis and a multi-scale community detection.

MATERIALS AND METHODS

Retrospective analysis of claims data from a large employer over 2 years was performed. The study cohort contained 827 patients diagnosed with diabetes. The cohort received care from 2567 and 2541 health care providers in the first and second year, respectively. Social network analysis was used to identify networks of health care providers involved in the care of patients with diabetes. A multi-scale community detection was applied to the network to identify groups of health care providers more densely connected. Social network analysis metrics identified influential providers for the overall network and for each community of providers.

RESULTS

Centrality measures identified medical laboratories and mail-order pharmacies as the central providers for the 2 years. Seventy-six percent of the detected communities included primary care physicians, and 97% of the communities included specialists. Pharmacists were detected as central providers in 24% of the communities.

DISCUSSION

Social network analysis measures identified the central providers in the network of diabetes health care providers. These providers could be considered as influencers in the network that could enhance the implication of promotion programs through their access to a large number of patients and providers.

CONCLUSION

The proposed framework provides multi-scale metrics for assessing care team relationships. These metrics can be used by implementation experts to identify influential providers for care interventions and by health service researchers to determine impact of team relationships on patient outcomes.

Parents' experiences of the caring encounter in the ambulance service-A qualitative study

AIMS AND OBJECTIVES

To explore the experiences of the caring encounter in the ambulance service among parents to children aged 0-14 years.

BACKGROUND

The care provided by the ambulance team is often associated with emergency medicine, traumatology and disaster medicine. But to develop care in the ambulance service, it is imperative to understand what the parents want and value in the care for their child.

DESIGN

A qualitative study design was used.

METHODS

Interviews was used for data collection, 16 caring encounters described by 14 parents were analysed using qualitative content analysis. Reporting of this research adheres to the COREQ guidelines.

RESULTS

The parents described the importance of giving the family enough time in the situation, creating a safe environment and involving the parents in the care. In cases where the parents felt insecure, there had been lack of communication and lack of sensitivity, and the ambulance team did not invite the parents to be participate in the care.

CONCLUSIONS

There is a need to strengthen the family-centred care in the ambulance service. Not inviting the parents in the care and use of equipment that was nonfunctioning or not adjustable for the children's age caused lack of trust and increased the level of stress among the parents. The parents had a positive experience and felt included when the team were calm, responsive and gave them the chance to be participants in their child's care.

RELEVANCE TO CLINICAL PRACTICE

The prehospital emergency care nurses need to be prepared for caring of children and their parents. The ambulance team also need to understand their role in providing care of children. Lack of confidence in treating children may be perceived as nonfamily-centred care. There is need of further training concerning family-centred care in the ambulance service.

The effect of safety communication network characteristics on safety awareness and behavior in a liquefied natural gas terminal

Relatively few studies have investigated the safety awareness and behavior that are substantially influenced by the characteristics of safety communication. It is very important to comprehend what kind of attributes play a role in adequate safety information flow in a communication network. For these reasons, the current study aimed to explore the effectiveness of safety communication on safety awareness and behavior. The data were collected by performing interviews with employees of teams at a liquefied natural gas terminal located in Pyeongtaek, South Korea. A social network analysis (SNA) was applied to visualize the pattern of the safety communication network and calculate the typical SNA metrics such as density, tie strength, betweenness and degree centrality. In addition, the number of communication channels was also considered as a crucial differentiator between teams. Then, a correlation analysis was applied to investigate the impact of calculated SNA metrics on safety awareness and behavior. As a result, density, tie strength, degree centrality and the channel variety showed a direct influence on safety awareness and behavior. Conversely, betweenness centrality was not an active metric. This study demonstrated that raising the level of SNA metrics such as density, tie strength and degree centrality, and using various channels to communicate safety information within teams, could support better safety awareness and behavior.

Putting the pieces together: EHR communication and diabetes patient outcomes

OBJECTIVES

This study seeks to determine how changes in electronic health record (EHR) communication patterns in primary care teams relate to quality of care and costs for patients with diabetes.

STUDY DESIGN

EHR-extracted longitudinal observational study.

METHODS

A total of 83 health professionals in 19 care teams at 4 primary care clinics associated with a large Midwestern university participated in the study. Counts of messages routed between any 2 team members in the EHR in the past 18 months were extracted. Flow-betweenness, defined as the proportion of information passed indirectly within the team, was calculated. The analysis related changes in team flow-betweenness to changes in emergency department visits, hospital stays, and associated medical costs for the teams' patients with diabetes, while adjusting for team face-to-face communication, patient-level covariates, comorbidities, team size, and clinic fixed effects.

RESULTS

Patient hospital visits increased by 13% (standard error [SE] = 6%) for every increase of 1 percentage point in team EHR message forwarding (ie, higher team flow-betweenness). Medical costs increased by $223 (SE = $105) per patient with diabetes in the past 6 months for every increase of 1 percentage point in team flow-betweenness.

CONCLUSIONS

Primary care teams whose EHR communication reached more team members indirectly (ie, via message forwarding) had worse outcomes and higher medical costs for their patients with diabetes. EHR team communication flow patterns may be an important avenue to explore in raising quality of care and lowering costs for patients with diabetes in primary care.

The Importance of External Contacts in Job Performance: A Study in Healthcare Organizations Using Social Network Analysis

There is evidence that relations between physicians and nurses within healthcare institutions might be shaped by informal aspects of such relations and by links to people external to the organization, with an impact on work performance. Social network analysis is underutilized in exploring such associations. The paper aims to describe physicians’ and nurses’ relationships outside their clinical units and to explore what kind of ties are related to job performance. A network analysis was performed on cross-sectional data. The study population consisted of 196 healthcare employees working in a public hospital and a primary healthcare centre in Spain. Relational data were analysed using the UCINET software package. Measures included: (i) sample characteristics; (ii) social network variables; and (iii) team performance ratings. Descriptive statistics (means, medians, percentages) were used to characterize staff and performance ratings. A correlational analysis was conducted to examine the strength of relationships between four different types of ties. Our findings suggest that external ties only contribute to improving the performance of physicians at both the individual and team level. They are focused on the decision-making process about the therapeutic plan and, therefore, might need to seek advice outside the workplace. In contrast, external ties are not relevant for the work performance of nurses, as they need to find solutions to immediate problems in a short period of time, having strong ties in the workplace. Social network analysis can illuminate relations within healthcare organizations and inform the development of innovative interventions.

Nursing Unit Design, Nursing Staff Communication Networks, and Patient Falls: Are They Related?

Purpose:

The purpose of this research is to (1) investigate the impact of nursing unit design on nursing staff communication patterns and, ultimately, on patient falls in acute care nursing units; and (2) evaluate whether differences in fall rates, if found, were associated with the nursing unit physical structure (shape) or size.

Background:

Nursing staff communication and nursing unit design are frequently linked to patient safety outcomes, yet little is known about the impact of specific nursing unit designs on nursing communication patterns that might affect patient falls.

Method:

An exploratory longitudinal correlational design was used to measure nursing unit communication structures using social network analysis techniques. Data were collected 4 times over a 7-month period. Floor plans were used to determine nursing unit design. Fall rates were provided by hospital coordinators.

Results:

An analysis of covariance controlling for hospitals resulted in a statistically significant interaction of unit shape and size (number of beds). The interaction occurred when medium- and large-sized racetrack-shaped units intersected with medium- and large-sized cross-shaped units.

Conclusion:

The results suggest that nursing unit design shape impacts nursing communication patterns, and the interaction of shape and size may impact patient falls. How those communication patterns affect patient falls should be considered when planning hospital construction of nursing care units.

Social network analysis of Iranian researchers in the field of violence

PURPOSE

The social network analysis (SNA) is a paradigm for analyzing structural patterns in social re- lations, testing knowledge sharing process and identifying bottlenecks of information flow. The purpose of this study was to determine the status of research in the fleld of violence in Iran using SNA.

METHODS

Research population included all the papers with at least one Iranian affiliation published in violence fleld indexed in SCIE, PubMed and Scopus databases. The co-word maps, co-authorship network and structural holes were drawn using related software. In the next step, the active authors and some measures of our network including degree centrality (DC), closeness, eigenvector, betweeness, density, diameter, compactness and size of the main component were assessed. Likewise, the trend of the published articles was evaluated based on the number of documents and their citations from 1972 to 2014.

RESULTS

Five hundred and seventy one records were obtained. The five main clusters and hot spots were mental health, violence, war, psychiatric disorders and suicide. The co-authorship network was complex, tangled and scale free. The top nine authors with cut point role and top ten active authors were identified. The mean (standard deviation) of normalized DC, closeness, eigenvector and betweeness were 0.449 (0.805), 0.609 (0.214), 2.373 (7.353) and 0.338 (1.122), respectively. The density, diameter and mean compactness of our co-authorship network were 0.0494, 3.955 and 0.125, respectively. The main component consisted of 216 nodes that formed 17% of total size of the network. Both the number of the documents and their citations has increased in the field of violence in the recent years.

CONCLUSION

Although the number of the documents has recently increased in the field of violence, the information flow is slow and there are not many relations among the authors in the network. However, the active authors have ability to influence the flow of knowledge within the network.

Social networks in health care teams: evidence from the United States

Purpose

The purpose of this paper is to synthesize existing evidence regarding health care team networks, including their formation and association with outcomes in various health care settings.

Design/methodology/approach

Network theory informed this review. A literature search was conducted in major databases for studies that used social network analysis methods to study health care teams in the USA between 2000 and 2014. Retrieved studies were reviewed against inclusion and exclusion criteria.

Findings

Overall, 25 studies were included in this review. Results demonstrated that health care team members form professional (e.g. consultation) and personal (e.g. friendship) networks. Network formation can be influenced by team member characteristics (i.e. demographics and professional affiliations) as well as by contextual factors (i.e. providers sharing patient populations and physical proximity to colleagues). These networks can affect team member practice such as adoption of a new medication. Network structures can also impact patient and organizational outcomes, including occurrence of adverse events and deficiencies in health care delivery.

Practical implications

Administrators and policy makers can use knowledge of health care networks to leverage relational structures in teams and tailor interventions that facilitate information exchange, promote collaboration, increase diffusion of evidence-based practices, and potentially improve individual and team performance as well as patient care and outcomes.

Originality/value

Most health services research studies have investigated health care team composition and functioning using traditional social science methodologies, which fail to capture relational structures within teams. Thus, this review is original in terms of focusing on dynamic relationships among team members.

A network model of communication in an interprofessional team of healthcare professionals: A cross-sectional study of a burn unit

Healthcare teams consist of individuals communicating with one another during patient care delivery. Coordination of multiple specialties is critical for patients with complex health conditions, and requires interprofessional and intraprofessional communication. We examined a communication network of 71 health professionals in four professional roles: physician, nurse, health management, and support personnel (dietitian, pharmacist, or social worker), or other health professionals (including physical, respiratory, and occupational therapists, and medical students) working in a burn unit. Data for this cross-sectional study were collected by surveying members of a healthcare team. Ties were defined by asking team members whom they discussed patient care matters with on the shift. We built an exponential random graph model to determine: (1) does professional role influence the likelihood of a tie; (2) are ties more likely between team members from different professions compared to between team members from the same profession; and (3) which professions are more likely to form interprofessional ties. Health management and support personnel ties were 94% interprofessional while ties among nurses were 60% interprofessional. Nurses and other health professionals were significantly less likely than physicians to form ties. Nurses were 1.64 times more likely to communicate with nurses than non-nurses (OR = 1.64, 95% CI: 1.01-2.66); there was no significant role homophily for physicians, other health professionals, or health management and support personnel. Understanding communication networks in healthcare teams is an early step in understanding how teams work together to provide care; future work should evaluate the types and quality of interactions between members of interprofessional healthcare teams.

Effectiveness of educational communication interventions for health professionals to improve quality of care in emergency departments: a systematic review protocol

The objective of this review is to evaluate the effectiveness of educational communication interventions for health professionals in emergency departments. The end result is to identify the specific types of communication based educational strategies utilized by emergency department health care professionals to enhance the quality of care for patients.

How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals

Background

Hospital emergency admissions have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical units. These pressures have an adverse impact on patient experience and potentially lead to suboptimal clinical decision-making. In response, a variety of innovations have been developed, but whether or not these reduce inappropriate admissions or improve patient and clinician experience is largely unknown.

Aims

To investigate the interplay of service factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners.

Methods

The project used a multiple case study design for a mixed-methods analysis of decision-making about admissions in four acute hospitals. The primary research comprised two parts: value stream mapping to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers and 282 practitioners of different specialties and levels. Additional data were collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources.

Findings

Patients’ experiences of emergency care were positive and they often did not raise concerns, whereas carers were more vocal. Staff’s focus on patient flow sometimes limited time for basic care, optimal communication and shared decision-making. Practitioners admitted or discharged few patients during the first hour, but decision-making increased rapidly towards the 4-hour target. Overall, patients’ journey times were similar, although waiting before being seen, for tests or after admission decisions, varied considerably. The meaning of what constituted an ‘admission’ varied across sites and sometimes within a site. Medical and social complexity, targets and ‘bed pressure’, patient safety and risk, each influenced admission/discharge decision-making. Each site responded to these pressures with different initiatives designed to expedite appropriate decision-making. New ways of using hospital ‘space’ were identified. Clinical decision units and observation wards allow potentially dischargeable patients with medical and/or social complexity to be ‘off the clock’, allowing time for tests, observation or safe discharge. New teams supported admission avoidance: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment. Senior doctors had a range of roles: evaluating complex patients, advising and training juniors, and overseeing ED activity.

Conclusions

This research shows how hospitals under pressure manage complexity, safety and risk in emergency care by developing ‘ground-up’ initiatives that facilitate timely, appropriate and safe decision-making, and alternative care pathways for lower-risk, ambulatory patients. New teams and ‘off the clock’ spaces contribute to safely reducing avoidable admissions; frontline expertise brings value not only by placing senior experienced practitioners at the front door of EDs, but also by using seniors in advisory roles. Although the principal limitation of this research is its observational design, so that causation cannot be inferred, its strength is hypothesis generation. Further research should test whether or not the service and care innovations identified here can improve patient experience of acute care and safely reduce avoidable admissions.

Funding

The National Institute for Health Research (NIHR) Health Services and Delivery Research programme (project number 10/1010/06). This research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

Exploring the use of social network analysis to measure communication between disease programme and district managers at sub-national level in South Africa

With increasing interest in maximising synergies between disease control programmes (DCP) and general health services (GHS), methods are needed to measure interactions between DCP and GHS actors. In South Africa, administrative integration reforms make GHS managers at decentralised level (district managers) responsible for the oversight of DCP operations within districts, with DCP managers (programme managers) providing specialist support. The reforms necessitate interdependence, but these actors work together ineffectively. Communication is crucial for joint working, but no research to assess communication between these actors has been done. This study explores the use of social network analysis (SNA) to measure the extent to which programme and district managers in South Africa communicate, using HIV monitoring and evaluation (M&E) as an exemplar. Data were collected from fifty one managers in two provinces during 2010-2011, to measure: a) one-on-one task-related communication - talking about the collation (verification, reporting) and use of HIV data for monitoring HIV interventions; and b) group communication through co-participating in management committees where HIV data are used for monitoring HIV interventions in districts. SNA measures were computed to describe actor centrality, network density (cohesion), and communication within and between respective manager groups. Block modelling was applied to identify management committees that connect respective manager groups. Results show HIV programme managers located at higher level communicated largely amongst themselves as a group (homophily), seldom talked to the district managers to whom they are supposed to provide specialist HIV M&E support, and rarely participated with them in management committees. This research demonstrates the utility of SNA as a tool for measuring the extent of communication between DCP and GHS actors at sub-national level. Actions are needed to bridge observed communication gaps in order to promote collaborative monitoring of HIV programme interventions within districts.

A systematic review of nurse-related social network analysis studies

BACKGROUND

Nurses frequently work as part of both uni- and multidisciplinary teams. Communication between team members is critical in the delivery of quality care. Social network analysis is increasingly being used to explore such communication.

AIM

To explore the use of social network analysis involving nurses either as subjects of the study or as researchers.

METHODS

Standard systematic review procedures were applied to identify nurse-related studies that utilize social network analysis. A comparative thematic approach to synthesis was used. Both published and grey literature written in English, Spanish and Portuguese between January 1965 and December 2013 were identified via a structured search of CINAHL, SciELO and PubMed. In addition, Google and Yahoo search engines were used to identify additional grey literature using the same search strategy.

RESULTS

Forty-three primary studies were identified with literature from North America dominating the published work. So far it would appear that no author or group of authors have developed a programme of research in the nursing field using the social network analysis approach although several authors may be in the process of doing so.

LIMITATIONS

The dominance of literature from North America may be viewed as problematic as the underlying structures and themes may be an artefact of cultural communication norms from this region.

CONCLUSIONS

The use of social network analysis in relation to nursing and by nurse researchers has increased rapidly over the past two decades. The lack of longitudinal studies and the absence of replication across multiple sites should be seen as an opportunity for further research.

IMPLICATION FOR NURSING AND HEALTH POLICY

This analytical approach is relatively new in the field of nursing but does show considerable promise in offering insights into the way information flows between individuals, teams, institutions and other structures. An understanding of these structures provides a means of improving communication.

Implementation of a team-based physician staffing model at an academic emergency department

Introduction

There is scant literature regarding the optimal resident physician staffing model of academic emergency departments (ED) that maximizes learning opportunities. A department of emergency medicine at a large inner-city academic hospital initiated a team-based staffing model. Its pre-interventional staffing model consisted of residents and attending physicians being separately assigned patients, resulting in residents working with two different faculty providers in the same shift. This study aimed to determine if the post-interventional team-based system, in which residents were paired with a single attending on each shift, would result in improved residents’ learning and clinical experiences as manifested by resident evaluations and the number of patients seen.

Methods

This retrospective before-and-after study at an academic ED with an annual volume of 52,000 patients examined the mean differences in five-point Likert-scale evaluations completed by residents assessing their ED rotation experiences in both the original and team-based staffing models. The residents were queried on their perceptions of feeling part of the team, decision-making autonomy, clinical experience, amount of supervision, quality of teaching, and overall rotational experience. We also analyzed the number of patients seen per hour by residents. Paired sample t-tests were performed. Residents who were in the program in the year preceding and proceeding the intervention were eligible for inclusion.

Results

34 of 38 eligible residents were included (4 excluded for lack of evaluations in either the pre- or post-intervention period). There was a statistically significant improvement in resident perception of the quality and amount of teaching, 4.03 to 4.27 (mean difference=0.24, p=0.03). There were non-statistically significant trends toward improved mean scores for all other queries. Residents also saw more patients following the initiation of the team-based model, 1.24 to 1.56 patients per hour (mean difference=0.32, p=0.0005).

Conclusion

Adopting a team-based physician staffing model is associated with improved resident perceptions of quality and amount of teaching. Residents also experience a greater number of patient evaluations in a team-based model.

Tumultuous atmosphere (physical, mental), the main barrier to emergency department inter-professional communication

BACKGROUND

A highly important factor in enhancing quality of patient care and job satisfaction of health care staff is inter-professional communication. Due to the critical nature of the work environment, the large number of staff and units, and complexity of professional tasks and interventions, inter-professional communication in an emergency department is particularly and exceptionally important. Despite its importance, inter-professional communication in emergency department seems unfavorable. Thus, this study was designed to explain barriers to inter-professional communication in an emergency department.

METHODOLOGY & METHODS

This was a qualitative study with content analysis approach, based on interviews conducted with 26 participants selected purposively, with diversity of occupation, position, age, gender, history, and place of work. Interviews were in-depth and semi-structured, and data were analyzed using the inductive content analysis approach.

RESULTS

In total, 251 initial codes were extracted from 30 interviews (some of the participants re-interviewed) and in the reducing trend of final results, 5 categories were extracted including overcrowded emergency, stressful emergency environment, not discerning emergency conditions, ineffective management, and inefficient communication channels. Tumultuous atmosphere (physical, mental) was the common theme between categories, and was decided to be the main barrier to effective inter-professional communication.

CONCLUSION

Tumultuous atmosphere (physical-mental) was found to be the most important barrier to inter-professional communication. This study provided a better understanding of these barriers in emergency department, often neglected in most studies. It is held that by reducing environmental turmoil (physical-mental), inter-professional communication can be improved, thereby improving patient care outcomes and personnel job satisfaction.

Barriers to implementation of a redesign of information transfer and feedback in acute care: results from a multiple case study

Background

Accurate information transfer is an important element of continuity of care and patient safety. Despite the demonstrated urge for improvement of communication in acute care, there is a lack of data on improvements of communication. This study aims to describe the barriers to implementation of a redesign of the existing model for information transfer and feedback.

Methods

A case study with six cases (i.e. acute care chains), using mixed methods was carried out in the Netherlands. The redesign was implemented in one acute care chain while the five other acute care chains served as control groups. Focus group interviews were held with members of the acute care chains and questionnaires were sent to care providers working in the acute care chains.

Results

Respondents reported three sets of barriers for implementation of the model: (a) existing routines for information transfer and feedback in organizations within the acute care chain; (b) barriers related to the implementation method and time period; and (c) the absence of a high ‘sense of urgency’ amongst providers in the acute care chain which would aid in improving the communication process.

Conclusions

This study shows that organizational factors play an important role in the success or failure of redesigning a communication process. Organizational routines can hamper implementation of a redesign if it differs too much from the routines of care providers involved. Besides focussing on provider characteristics in the implementation of a redesigned process, specific attention should be paid to unlearning existing organizational routines.