Communication of preclinical emergency teams in critical situations: A nationwide study

Background The emergency medical service as a high-risk workplace is a danger to patient safety. A main factor for patient safety, but also at the same time a main factor for patient harm, is team communication. Team communication is multidimensional and occurs before, during, and after the patient’s treatment. Methods In an online based, anonymous and single-blinded study, medical and non-medical employees in the emergency medical services were asked about team communication, and communication errors. Results Seven hundred and fourteen medical and non-medical rescue workers from all over Germany took part. Among them, 72.0% had harmed at least one patient during their work. With imprecise communication, 81.7% rarely asked for clarification. Also, 66.3% saw leadership behavior as the cause of poor communication; 46.0% could not talk to their superiors about errors. Of note, 96.3% would like joint training of medical and non-medical employees in communication. Conclusion Deficits in team communication occur frequently in the rescue service. There is a clear need for uniform training in team and communication skills in all professions.


Introduction
Acute and critically ill patients require fast and precise life-saving treatment. The German Emergency Medical Service (EMS) handles more than eleven million missions a year. The

Materials and methods
In an online based study emergency health care workers were interviewed. The study was descriptively planned, voluntary, anonymous, single-blinded, and without monetary compensation for the participants. We sent non-personalized invitations by e-mail and letters to 1000 German EMS stations and to regional medical directors of EMS who wanted to support the study, medical associations, and promoted the study in an EMS professional journal. The heads of the EMS stations were called upon to make their staff aware of the study. We used the program www.surveymonkey.de to collect responses to the questionnaire. Data were collected online from 01 August 2016 to 20 April 2017. As an indication of the regional distribution of the participants, the postcode of the place of residence was recorded.
In terms of social empirical research, we used a standardized questionnaire survey to achieve a high degree of objectivity in implementation. We wanted to record the purely subjective experiences and opinions of the target group. The questionnaire consisted of single and multiple-choice questions as well as open questions. They were based on 17 hypotheses regarding communication and patient safety during emergency missions. The individual items of the questionnaire were selected from a previously created universe of items. The universe of items was created based on a thorough literature search in the main areas of communication and risk management. The test structure was subjected to an expert rating. We did not perform a classical hypothesis-based case number calculation because we planned a descriptive, non-interventional study.
As members of the Goethe-University of Frankfurt we were consulted by the Institute for Biostatistics and Mathematical Modelling at the Centre for Health Sciences, Goethe-University Frankfurt. The ethics commission of the State Medical Association of Hesse saw no need for a formal ethical review as the data were being collected anonymously (decision reference number FF67/2016). The study was conducted in accordance with the tenets of the Declaration of Helsinki. The participants were invited in writing via all German EMS stations, the medical directors of EMS in Germany.

Inclusion criteria
1. Paramedics (PMs) with two years training according to the law on the profession of emergency paramedic.
2. Emergency paramedics (EPMs) with three years training according to the respective medical associations of the German federal states.

Staff of a German EMS.
5. Voluntary and unpaid participation in the study.
6. Consent to the privacy policy.

Exclusion criteria
1. Failure to meet one or more inclusion criteria.

Data analysis
Due to its descriptive nature, we did not perform classical hypothesis-based case number calculations. The questionnaire consisted of 53 questions which, in addition to demographic information, asked about attitudes with respect to communicative behavior, experiences of errors in patient care and resulting consequences, and associations between communication deficits and maltreatment of patients during care. All statistical analyses were performed using BiAS version 11.06 for Windows (epsilon-Verlag, Frankfurt, Germany).

Results
Of the 722 sample data received, 714 met the inclusion criteria. Participants (female 17.7%, male 82.3%) had an average age of 35.9±10.5 years and reported an average of 12.5±9.4 years of work experience. PMs (53.5%), EPMs (18.4%), and EPs (28.1%) participated from all over Germany Table 1. The geographical distribution of participants within Germany was homogeneous.
25.1% of the participants expressed a very high level of interest in the topic of communication and 53.3% a high level.

Patient harm
72.0% the participants stated that they had harmed a patient through their work. In 5.6% of cases, this harm led to disability or death.

Communication errors
We asked participants about their self-perception of their own communication as receivers and senders of information. Thereby self-reported communication behavior was heterogeneous Table 2.
Communication deficits during patient care can be very different in kind. We operationalized interesting aspects with a focus on the technique of closed-loop communication (i.e. message given, repeated, confirmed) Table 3. In all, 89.7% indicated that the combination of certain team members leads to communication errors more frequently.
Working in EMS can be stressful. Stress as a physiological reaction of the body can lead to a change in perception and behavior. When the participants have to work in stressful situations, they reported a change in their communication Table 4.
When asked about general reasons for poor communication, the participants responded with character traits of colleagues (85.7%), leadership behavior (66.3%), work organization (51.3%) and character traits of one's own person (34.6%). Participants justified their own poor communication with time pressure (35.1%) and multiplicity number of tasks (58.4%). 14.2% did not want to appear unfocused and therefore tend to poor communication. We believe that current deficits in communication during patient care will have an impact on communication behaviors in future EMS missions. The participants reported about experienced and feared effects of harmful communication Table 5.
As an additional indicator of the meaningfulness of team communication, we see the participants' interest in the wish to improve their own skills of communication Table 6. In all, 43.2% stated that they fully agreed and 45.8% rather agreed that general communication standards and treatment guidelines should be used in EMS missions.
Examination for associations between age, years of experience, and professions revealed no clear links.

Discussion
With respect to age, sex, and professional training as EMS worker, interviewees are representative for Germany [16,17]. The number of evaluable questionnaires is noteworthy in view of the informal invitation to participate. This may reflect the high level of interest in the topic of communication. For the first time the present study provides an insight into the perception and experience of communicative behavior and its deficits in the EMS.

Patient harm
The number of emergency staff indicating having caused harm to patients by communication deficits is high. For the first time we are able to quantify the degree because other studies had only researched selected cases [3]. The extent of patient harm is sometimes considerable (disability or death). The experience of mistakes seems to be an everyday occurrence that is little known to the general public (population, EMS staff) outside of small expert circles. The evaluation of the German Critical Incident Reporting System for Emergency Medicine [3] identified a deficit in team communication as the trigger for 27% of cases of patient harm. The currently reported error frequency is not tolerable, and the self-assessment probably underestimates the true frequency of error.

Communication errors
The majority of the interviewees attested themselves a rather good communication behavior. The low level of reported misunderstandings also fits in with this conclusion. However, this is subjective self-perception, which can be distorted. At the same time, the severity of the communication deficit does not correlate with its impact. According to J. Reason's Swiss Cheese model (cumulative act effect) [1], even minor misunderstandings can have serious consequences.
Due to the heterogeneous results, we suspect that the concept of closed-loop communication [18,19] is not comprehensively known in German EMS. Probably the participants use components of this concept rather unconsciously. But the conscious use of closed-loop communication could be effective in reducing communication deficits [19]. And although the team members were rarely addressed by name, they seem to know more often that they were being addressed. This may be due to the fact that the majority of EMS deployments only occur in teams of two. Or there is non-verbal communication. The fact that the participants attested themselves a good communication behaviour and at the same time they did not master closedloop communication completely, points to clear knowledge gaps.
We suggest the integration of closed-loop communication into the EMS training. EMS teams should use this communication tool in any emergency, no matter how uncomplicated, to reduce misunderstandings and their consequences.
The participants lack strategies to maintain effective communication in stressful situations. This creates an alarming threat to patient safety. Deficits in vocational training are most likely. Again, there is a discrepancy between self-assessment and requirements for good communication in high-risk workplaces.
The causes of poor communication are more likely to be seen in other team members than in themselves. We suggest that behind this result is a lack of ability to introspect and a lack of understanding of the mechanisms of team communication. More experienced employees see considerable causes for poor communication in the leadership behavior of their superiors and the organization of work. The organizational structure of EMS in Germany demands formation of ad hoc teams. This seems to be a key element in causing errors as the teams are not well trained for this kind of cooperation. The different professional groups are neither interlocked in training nor can they practice collegial cooperation outside work assignments. In addition, there is an asymmetrical relationship between the physician and non-physician team members due to differences in professional training and role perception. This asymmetry has not yet been balanced out or addressed constructively.
The consequences of poor communication are significant for the participants. Fear of sanctions, shame and the loss of reputation are major outcome risks. They do not talk to their own superiors. This makes it difficult for superiors to uncover systematic problems and to improve

Limitations
In interpreting the data presented, it should be borne in mind that more motivated and interested employees of the rescue service might have responded. Employees with less interest in the topic or their profession or reduced communication skills may have declined to participate. The study is not an objective observation but provides information about subjective perceptions. Emergency medical technicians, who are widespread in the rescue service for cost reasons and receive only a short professional training, were not interviewed.