Negotiationof Teamwork: How nurses and physiciansas a team

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Negotiation of Teamwork: How nurses andphysicians as a team consider their ESI-based triage level in older ED patients: an Interpretive DescriptionThomas Dreher-Hummel, RN, MSc University Hospital Basel, Emergency Department

Christian Nickel, MD University Hospital Basel, Emergency Department

Dunja Nicca, Rn, PhD University Basel, Institute of Nursing Science, Department Public Health

Florian Grossmann, RN, MSc University Hospital Basel, Department Medicine

Notfallzentrum

Disclosure

Interest in the care of older people

11.09.2018Negotiation of Teamwork / EUSEM / Thomas Dreher-Hummel 2

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Background

1/3 ED patients > 65y, fastest growing population (Rogers, 2009; Vilpert, 2014)

Atypical presentation of older patients (Nemec et al. 2010)

23 % of older ED patients undertriaged (Grossmann et al., 2014)

New team approach in triage and assessment of ED patients(Lauks et al., 2016)

Unclear how shared decision making and collaboration in team triage works.

How nurses and a physicians as a team consider their ESI-based triage level in older ED patients?


Setting

2008 ESI 14 Nurses

2014 MTE35 Nurses

14 Senior Physicians

52 000 ED Patients


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Quick Look Nurse

Initial registration of patient dataRecognition of patients who should not wait

ESI 1 or 2


Medical Team Evaluation

Senior physician and nurse 9.00 am to 10 p.m

12.00 to 6 p.m. two teamsmax. 10 min/Patient


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Methods

Qualitative study design Interpretive description (Thorne, 2008)Purposeful selection of informants (7 nurses and 5 physicians) Open ended interviews (mean duration 55 minutes)Written informed consent


Collaboration

Role Acceptance

Exposure

ofT

ime P

ressure

Preferences ofTriage System

functioning

Not functioning

Findings


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Preferences of Triage Systems / Team Evaluation

In older Patients we oftenhave a lack of information,…, is seen by the intern and at

the end the senior asks „how far should we go“ it`s a delay

There is a better „bigpicture“ when two

professions triage. Weprovide the initial treatment

plan


Preferences of Triage System / Nurse led Triage

Physicians triage differently to nurses: If the physician

suspects a diagnosis,…,they go further and further, why, …, I

think the purpose of triage is to bring the patient as quickly as

possible to the correcttreatment area


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Exposure of Time Pressure

Patience in triage of older patientsis very important,…, but it is a bigchallenge not to lose patience ifthere are a lot of patients waiting


Quick Look Nurse – The Safety Net


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Exposure of Time Pressure - Splitting the Team

Some teams are splitting too late,…,it should not

happen that 6,7 or 8 patients are waiting to be

triaged.


Exposure of Time Pressure - Stay together as Team

Indeed it is a bigchallenge to take your

time,…,I think we have to stay together as team

and maintain high qualitytriage, if not it loses its

function


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Role Acceptance

I noticed that the way I handle medical historytaking has improved. I have benefited from

teamwork

It is stressful if youhave to take vital

signs, do dressings, then it is very helpful

to be in a team


Role Acceptance

I am unhappy if thephysician immediatelytakes control and I am only good enough to

take vital signs and do dressings.

The benefit thephysicians add is

evaluation and planning. But some of the nursingcolleagues get nervousand sometimes they just

leave the room


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Collaboration

You have to be willing to talk withyour partner and each person has

to be open minded and want to work in a team.


Discussion


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Discussion / Different Triage Systems

Burstroem et al. 2016Lauks et al. 2016

Interviewees had no consensus about efficiency of team evaluation vs. nurse led triage, especially in times of crowding


Discussion – Exposure of Time Pressure

ROC Prediction morbidityRohacek et al. 2015

ROC Prediction mortalityBrabrand et al. 2014


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Discussion / Role Acceptance

Interprofessional collaboration is affected byconfidence, respect, open communication but also organisational structure and philosophy, leadership and power struggles between professions (Martin-Rodriguez et al., 2005)


Discussion / Well Functioning Collaboration

Better patient outcomes (Martin et al. 2010)

Improved patient safety(Welp & Manser, 2016)

Positive job satisfaction(Welp & Manser, 2016)


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Strenght & Limitations

No generalisation of findings in a qualitative studySingle site studyPurposeful selection of interviewees for diversificationOngoing discussion of findings in masterclass seminars and

investigation team Findings are underpinned by quotations


Conclusion

• A well functioning team triage is much valued andadvantageous

• Interprof. collaboration could be improved bycollective vision and culture, open communicationand lowered hierarchical structures

• Methods of Practice Development could support thiscultural change


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Thank You for Support


Thank You for Attention


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Brabrand, M., Hallas, J., & Knudsen, T. (2014). Nurses and physicians in a medical admission unit can accurately predict mortality of acutely admitted patients: a prospective cohort study. Plos One, 9(7), e101739-e101739. doi: 10.1371/journal.pone.0101739

Burström, L., Engström, M.-L., Castrén, M., Wiklund, T., & Enlund, M. (2016). Improved quality and efficiency after the introduction of physician-led team triage in an emergency department. Upsala Journal Of Medical Sciences, 121(1), 38-44. doi: 10.3109/03009734.2015.1100223

Grossmann, F. F., Zumbrunn, T., Ciprian, S., Stephan, F.-P., Woy, N., Bingisser, R., & Nickel, C. H. (2014). Undertriage in older emergency department patients--tilting against windmills? Plos One, 9(8), e106203-e106203. doi: 10.1371/journal.pone.0106203

Lauks, J., Mramor, B., Baumgartl, K., Maier, H., Nickel, C. H., & Bingisser, R. (2016). Medical Team Evaluation: Effect on Emergency Department Waiting Time and Length of Stay. Plos One, 11(4), e0154372. doi: 10.1371/journal.pone.0154372

Martin, J. S., Ummenhofer, W., Manser, T., & Spirig, R. (2010). Interprofessional collaboration among nurses and physicians: making a difference in patient outcome. Swiss Medical Weekly, 140, w13062-w13062. doi: 10.4414/smw.2010.13062

Nemec, M., Koller, M. T., Nickel, C. H., Maile, S., Winterhalder, C., Karrer, C., . . . Bingisser, R. (2010). Patients presenting to the emergency department with non-specific complaints: the Basel Non-specific Complaints (BANC) study. Academic Emergency Medicine, 17(3), 284-292 289p. doi: 10.1111/j.1553-2712.2009.00658.x

Rogers, D. (2009). The increasing geriatric population and overcrowding in the emergency department: one hospital's approach. JEN: Journal of Emergency Nursing, 35(5), 447-450. doi: 10.1016/j.jen.2009.02.009

Rohacek, M., Nickel, C. H., Dietrich, M., & Bingisser, R. (2015). Clinical intuition ratings are associated with morbidity and hospitalisation. Int J Clin Pract, 69(6), 710-717. doi: 10.1111/ijcp.12606

San Martín-Rodríguez, L., Beaulieu, M., D'Amour, D., & Ferrada-Videla, M. (2005). The determinants of successful collaboration: a review of theoretical and empirical studies. Journal of Interprofessional Care, 19, 132-147.

Thorne, S. (2008). Interpretive Description: Left Coast Press. Vilpert, S., Ruedin, H. J., Trueb, L., Monod-Zorzi, S., Yersin, B., & Büla, C. (2013). Emergency department use by

oldest-old patients from 2005 to 2010 in a Swiss university hospital. BMC Health Services Research, 13, 344-344. doi: 10.1186/1472-6963-13-344

Welp, A., & Manser, T. (2016). Integrating teamwork, clinician occupational well-being and patient safety -development of a conceptual framework based on a systematic review. BMC Health Services Research, 16, 281-281. doi: 10.1186/s12913-016-1535-y



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Negotiationof Teamwork: How nurses and physiciansas a team