Impact of Built Environment on Situational Awareness in the ED: A Socio-Technical Approach to Improve Handoffs

Rutali Joshi (Clemson University)

Emergency departments (ED) are chaotic and stressful work environments. With the need to be open 24 hours it is imperative that staff work in shifts. Transition in shifts, also called as handoffs, are crucial episodes of information exchange directed toward patient care interactions. Errors during handoffs are deemed as a cause of approximately 70% of sentinel events in the ED affecting patient safety. In recent research, these errors are attributed to compromised situational awareness (SA). SA has been operationalized as individual or team perception of the surrounding environment and its elements at a certain point in time, understanding of the current status, prediction of a future situation and/or identification of a trend in the system (Endsley, 1995a; Fernandes & Braarud, 2015).

This study outlines a comprehensive clinician-centered systems framework for SA focusing on the role of the built environment. For the purpose of this study, published empirical literature at the intersection of handoffs, SA, and healthcare built environments were identified and analyzed in detail. Additionally, 48 hours of ED observations were conducted to uncover handoff issues. Gaps in existing literature were identified and inferences drawn from human factors, cognitive psychology and SA theories. This study offers a holistic understanding of the impact of built environment on SA during medical handoffs in the ED.

Literature suggests that location and content of handoffs, communication patterns, interruptions and multitasking behaviors, technological factors (like white boards, EHR), operational factors (staffing ratios, workload, team work and training), and personal limitations (fatigue, cognitive bias, inattention, collective sense-making abilities) impact handoffs. Though SA theories in fields like military and aviation are commonly based on socio-technical systems, research on medical handoffs is found to be limited to inadequate communications, isolated from rest of the components of the socio-technical system like people, technology, environment, and their interactions.