Interprofessional teamwork before and after organizational change in a tertiary emergency department: An observational study

Figures & data

Figure 1. The ED organization and process of triage post-intervention.

Note. Patients entered the ED via ambulance transport or the waiting room, where a registered nurse, nurse assistant, and a physician in the triage team assessed the patient during daytime hours on weekdays. An administration desk, at which clerical staff performed registration of all patients visiting the ED, was connected to all the teams. The medical team worked across three pods, according to the severity of the patient’s symptoms. The surgical team worked across two pods, in close connection to the triage team pod, trauma team pod, and ambulance entrance, and managed all types of patient conditions regardless of severity. Patients with less-serious conditions were referred directly to either a registered nurse with extended ED training or the “Stream team” (this was later modified in terms of placing the consultant in the triage team pod; see, Figure 2).

Figure 2. Department-wide strategies implemented in the ED between 2016 and 2019.

Note. Targets for intervention are shown with actions implemented between the time periods.

Figure 3. Domains of interprofessional communication in the observation tool used in the pre- and post-intervention periods.

Note. The observation tool intended to observe the teamwork processes used by HCPs during patient assessment in the ED.

Table 1. Characteristics of each interprofessional teamwork in single observation ^a

Total of single observations with teamwork characteristics n = 392	Pre-n = 192	Post-n = 200	Pre-n = 192	Post-n = 200	Pre-n = 192	Post-n = 200	Pre-n = 192	Post-n = 200
	Physician n = 283		Registered nurse n = 383		Nurse assistant n = 299		Administrative staff n = 136
Total number of HCPs in each discipline observed, pre-intervention and post-intervention periods	n = 96	n = 187	n = 191	n = 192	n = 151	n = 148	n = 32	n = 104
Years of professional experience (mean/SD)	9.8 (9.0)	8.8 (6.6)	4.4 (6.5)	4.5 (5.0)	11.25 (13.2)	12.1 (14.3)	2.6 (1.4)	5.0 (4.3)
Intern/resident physician, n (%)	31 (32.3%)	74 (39.6%)	0	0	0	0	0	0
Consultant physician, n (%)	32 (33.3%)	97 (51.9%)	0	0	0	0	0	0
Specialization in each profession, n (%)
Medicine	28 (29.1%)	77 (41.2%)	2 (1.0%)	0	0	0	0	0
Surgery	3 (3.1%)	18 (9.8%)	0	0	0	0	0	0
Neurology	0	2 (1.1%)	0	0	0	0	0	0
Anesthesia	0	0	4 (2.1%)	0	0	0	0	0
Obstetrics/Midwifery	0	0	1 (0.5%)	13 (6.8%)	0	0	0	0
Emergency care	0	63 (33.4%)	0	0	0	4 (2.7%)	0	0
Primary care/Home care	0	5 (2.7%)	0	0	0	0	0	0
Registered Nurse with extensive ED training	0	0	0	13 (6.8%)	0	0	0	0

ED, emergency department; HCP, Healthcare Professionals; Pre-, Pre-intervention (2016); Post-, Post-intervention (2019).

^aThe unit of analysis is a single observation. A total sample of observations (n = 392), collected pre-intervention (n = 192) and post-intervention (n = 200).

Table 2. Observed interprofessional communication behaviors related to environmental factors during the coordination of patient care for all HCPs (n = 392 single observations ^a)

	Pre-intervention (n = 192)	Post-intervention (n = 200)	p-value
Domain 1. HCPs who initiated communication across the 392 single observations ^b, d, n (%)	162 (84.4%)	131 (65.5%)	.009
Across groups, n (%) (without other ^e)	154 (80.2%)	123 (61.5%)	.033
Other ^e, n (%)	8 (4.2%)	8 (4.0%)	NA
Physician, n (%)	4 (2.1%)	12 (6.0%)	.072
Registered nurse, n (%)	100 (52.1%)	78 (39.0%)	.011
Nurse assistant, n (%)	50 (26.0%)	33 (16.5%)	.026
Domain 2. HCPs contribution to patient assessment over all the single observations ^b
Across groups, n (%)	226 (118%)	452 (226%)	< .001
Physician, n (%)	19 (9.9%)^2	148 (74.0%)^2	< .001
Registered nurse, n (%)	129 (67.2%)^2	186 (93.0%)^2	.023
Nurse assistant, n (%)	78 (40.6%)^2	118 (59.0%)^2	< .001
Domain 3. Interprofessional communication processes used across the 392 observations ^b
SBAR ^f, n (%)	126 (65.6%)	122 (61.0%)	.734
“Speaking up” ^f, n (%)	23 (12.0%)	26 (13.0%)	.115
“Closed loop” ^f, n (%)	26 (13.5%)	12 (6.0%)	.291
Domain 4. Total number of team interruptions (n) and percentage of interruptions over all the single observation sessions ^b (%)	103 (53.6%)	78 (39.0%)	.004
Primary source of interruption across all observation sessions ^c, n (%)	161 (100%)	142 (100%)
Colleague outside team, n (%)	67 (41.6%)	45 (31.7%)	.007
Colleague within team, n (%)	36 (22.3%)	32 (22.5%)	.506
Total colleagues (outside + within), n (%)	103 (64.0%)	77 (54.2%)	.003
Phone, n (%)	33 (20.5%)	20 (14.1%)	.040
Emergency call alert, n (%)	3 (1.9%)	8 (5.6%)	.221
Patient, n (%)	6 (3.7%)	15 (10.6%)	.072
Patient support person (e.g., family member), n (%)	5 (3.1%)	11 (7.7%)	.202
Hospital porter, n (%)	11 (6.8%)	11 (7.7%)	1.0

^aUnit of analysis is a single observation. ^b Percentage of total single observations pre-intervention or post-intervention. ^c Percentage frequency of observed variable. ^d Non-Applicable (patient not present). ^e Patient, patient support person or ambulance staff. ^f Situation Background Action Recommendation, a hand-over tool used in the emergency department (Woodhall et al., 2008). ^g Interprofessional communication tools in the emergency department (Rall et al., 2015).

Table 3. Observed interprofessional communication behaviors related to environmental factors during coordination of patient care for each ED team ^a

Area within ED	Triage team (n = 241) Pre-intervention, n = 120; Post-intervention, n = 121								Medical team (n = 83) Pre-intervention, n = 43; Post-intervention, n = 40						Surgical team (n = 49) Pre-intervention, n = 19; Post-intervention, n = 30						Trauma team (n = 19) Pre-intervention, n = 10; Post-intervention, n = 9
n (%)	Pre-	Post-	Pre-	Post-	Pre-	Post-	Pre-	Post-	Pre-	Post-	Pre-	Post-	Pre-	Post-	Pre-	Post-	Pre-	Post-	Pre-	Post-	Pre-	Post-	Pre-	Post-	Pre-	Post-	Pre-	Post-
Profession	Physician		RN		NA		Admin ^g		Physician		RN		NA		Physician		RN		NA		Physician		RN		NA		Admin ^g/Ambulance
Domain 1. HCPs who initiated thecommunication ^b, d, n (%)	0	7 (5.8%)	74(61.7)	76(62.8)	46(38.3)	32(26.4)	0	4(3.3)	1 (2.3)	1(2.5)	14(32.6)	0	2(4.7)	0	0	0	8(42.1)	0	1(5.3)	0	3 (30.0)	4(44.4)	4(40.0)	2(22.2)	1(10.0)	1(11.1)	0/0	0/2 (0/22.2)
Domain 2. HCPs contribution to patient assessment ^b, d, n (%)	10(8.3)	71(58.7)	119(99.2)	110(90.9)	68(56.7)	49(40.5)	0	0	0	39(97.5)	0	39(97.5)	0	38(95.0)	0	29(96.7)	0	28(93.3)	0	23(76.7)	9 (90.0)	9(100.0)	10(100.0)	9(100.0)	10(100.0)	8(88.9)	0/0	0/0
Domain 3. Interprofessional communication processes ^b
SBAR ^e, n (%)	0	6 (5.0)	95 (79.2)	60 (49.6)	0	2 (1.7)	0	0	0	0	9 (20.9)	17 (42.5)	0	1 (2.5)	0	5 (16.7)	8 (42.1)	9 (30.0)	0	0	0	3 (33.3)	1 (10.0)	2 (22.2)	0	0	0/7 (0/70.0)	0/4 (0/44.4)
“Speaking up” ^f, n (%)	1 (0.8)	2 (1.7)	3 (2.5)	5 (4.1)	3 (2.5)	4 (3.3)	0	0	0	1 (2.5)	6 (14.0)	2 (5.0)	0	0	2(10.5)	0	1 (5.3)	1 (3.3)	2 (10.5)	2 (6.7)	1 (10.0)	4(44.4)	0	3 (33.3)	4 (40.0)	2 (22.2)	0/0	0/0
“Closed loop” ^f, n (%)	3 (2.5)	0	3 (2.5)	3 (2.5)	9 (7.5)	3 (2.5)	0	0	0	0	3 (7.0)	0	0	0	0	0	3 (15.8)	0	1 (5.3)	0	2(24.2.0)	1 (11.1)	0	5 (55.6)	1 (10.0)	0	0/1 (0/10.0)	0/0
n (%)	Pre-				Post-				Pre-			Post-			Pre-			Post-			Pre-				Post-
Domain 4. Number of interrupted teams across all single observations ^b, n (%)	42 (35.0)				21 (17.4)				39 (90.7)			36 (90.0)			16 (84.2)			18 (60.0)			6 (60.0)				3 (33.3)
Primary source of interruption across all single observations ^c, n	43				24				76			67			36			49			6				3
Colleague outside team, n (%)	36 (83.7)				16 (66.7)				22 (28.9)			20 (29.9)			3 (8.3)			9 (18.4)			6 (100.0)				1 (33.3)
Colleague within team, n (%)	0				0				26 (34.2)			20 (29.9)			10 (27.8)			12 (24.5)			0				0
Phone call, n (%)	5 (11.6)				4 (16.7)				17 (22.4)			10 (14.9)			11 (30.5)			6 (12.2)			0				0
Emergency alert, n (%)	1 (2.3)				3 (12.5)				1 (1.3)			0			1 (2.8)			4 (8.2)			0				1 (33.3)
Patient, n (%)	0				1 (4.2)				3 (3.9)			7 (10.4)			3 (8.3)			7 (14.3)			0				0
Patient support (e.g., family member), n (%)	0				0				1 (1.3)			3 (4.5)			4 (11.1)			7 (14.3)			0				1 (33.3)
Hospital porter, n (%)	1 (2.3)				0				6 (7.9)			7 (10.4)			4 (11.1)			4 (8.2)			0				0

ED, emergency department; RN, registered nurse; NA, nurse assistant; Admin; administrative staff; Pre-, Pre-intervention (2016); Post-, Post-intervention (2019).

^aUnit of analysis is a single observation. ^b Percentage of total observations pre-intervention or post-intervention. ^c Percentage frequency of observed variable. ^d Non-Applicable (patient not present). ^e Situation Background Action Recommendation, a hand-over tool used in the ED (Woodhall et al., 2008). ^f Interprofessional communication tools in the ED (Rall et al., 2015). ^g Administrative staff observed only in triage and trauma teams.

Figure 4. Number of interruptions per single observation (%), pre- and post-intervention.

Note. Interruptions were observed 0–9 times per single observation in the team pods. Statistical evaluation showed lower mean numbers of interruptions per observation post-intervention (2019) than pre-intervention (2016), in the triage team (0.5 vs 0.2; p = .003). The same evaluation showed no statistical differences between the pre-intervention and post-intervention values for the medical team (2.6 vs 2.7; p = .438), surgery team (2.6 vs 1.8; p = .286) or trauma team (0.9 vs 0.33; p = .138).

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