1 INTRODUCTION

A challenge arising from the COVID-19 crisis is the effective communication among healthcare workers donned in personal protective equipment (PPE). The use of face masks greatly hinders communication by obscuring auditory signals. Surgical masks attenuate information-carrying frequencies by 4 dB, whereas N95 masks do so by 12 dB.¹

During this period, patients exhibiting respiratory symptoms were assigned to special clinics outside the emergency department (ED) in the National Taiwan University Hospital (NTUH) and received care from a dedicated COVID-19 team equipped with full PPE. This gear comprised an N95 mask underneath a surgical mask, a hair cap, goggles, a face shield, gloves, a gown, and shoe coverings. If patients tested negative for COVID-19, their care was transitioned to a non-COVID-19 team (Supplementary Figure S1). Conversely, those who tested positive remained in the specialized clinic under the COVID-19 team's management.

A real-time communication tool was integrated into the hospital information system.² The development environment utilized Microsoft Visual Studio with ASP.NET C# for web and program development. The information technology personnel embedded this messaging system into the medical information system used in the ED. Unlike traditional instant messaging software, which is user-centered, this system is patient-centered, with healthcare personnel acting as satellites to collaboratively exchange real-time information regarding the patient's condition. Its features include the ability to send text to specific staff members and to generate pop-up reminders (Supplementary Figure S2). This study aimed to evaluate the relationship between the use of this communication tool and the ED length of stay (LOS) for patients with respiratory symptoms.

2 METHODS

The retrospective study used the de-identified data of ED patients in the NTUH, a tertiary medical center, from January 2020 to December 2022. The ED has approximately 100,000 visits annually. The study was approved by the institutional review board of the NTUH (202107160RINC) and registered at ClinicalTrials.gov (NCT05597371). Informed consent was waived due to the retrospective study design and the use of de-identified data.

The study population included patients with respiratory symptoms with the triage level 2–5 using the Taiwan Triage Acuity System (TTAS).³ The TTAS is a five-level triage system similar to the Canadian Triage and Acuity Scale (CTAS). It categorizes patients based on urgency into resuscitation, emergent, urgent, less urgent, and nonurgent levels, each with a corresponding recommended waiting time. Patients with the triage level 1 were excluded because the other teleconference system was used.⁴

LOS was defined from the ED registration to leaving the ED (discharge or admission) compared between patients with the tool use and not. The analysis was further categorized by the triage level. All data were analyzed using the SAS software (SAS 9.4, Cary, North Carolina, USA). LOS was expressed as medians and interquartile ranges (IQRs) and analyzed using Wilcoxon's rank-sum test. A p-value of less than 0.05 was significant.

3 RESULTS

A total of 47,296 patients with respiratory symptoms were included in the study, with 9133 (19%) managed using the communication tool. Nurses exclusively used the tool to remind physicians about patient disposition. Compared to those who did not managed using the tool (n = 38,163, 81%), LOS was significantly shorter for patients for whom the tool was utilized. This effect remained significant across different triage levels (Table 1).

4 DISCUSSION

Effective communication among healthcare workers is crucial in emergency settings. However, this becomes increasingly challenging during the COVID-19 pandemic. Researchers have reported the use of Nightingale communication methods, which included color stripes and formal hand signals, to improve communication in the intensive care unit.⁵ In this study, ED healthcare workers utilized the communication tool as an alternative to traditional methods, such as telephone or face-to-face communication, in noncritical situations. The use was associated with reducing ED-LOS.

The triage system ensures that ED patients are prioritized based on the severity of their conditions, allowing for the appropriate allocation of resources and timely treatment.³ In our study, patients across different triage levels experienced shorter LOS when healthcare workers used the tool. The results indicate that the platform can facilitate the ED process for patients of varying severity.

This study has limitations. First, the data were from a single-institution, limiting the ability to generalize the findings externally. However, we proposed an effective communication tool embedded in the hospital information system that can be used in any healthcare setting, preparing for future emerging infectious disease outbreaks. Second, the communication tool was used for some patients. It is unclear whether more complicated patients required more direct interactions, such as face-to-face or telephone encounters, instead of using the communication tool. However, patients with the same triage level generally exhibit similar vital signs and risks of respiratory failure. Additionally, face-to-face communication was not restricted in this retrospective study. Healthcare workers could use face-to-face communication in addition to the communication tools. Therefore, the results remained comparable between those who used the communication tools and those who relied solely on face-to-face communication. Moreover, the content of the messages primarily concerned disposition rather than further treatment. Third, we used de-identified data, meaning individual patient details, including COVID-19 test results, were not available, which could potentially confound LOS. However, since the data were collected retrospectively, healthcare workers were unaware of the study at the time, minimizing the Hawthorne effect and accurately reflecting real-world practice. Also, the manpower allocated to patients with respiratory symptoms remained consistent at our ED during the COVID-19 pandemic, minimizing the confounding effects.

In conclusion, this communication tool provides a potential solution for communication among healthcare workers wearing full PPEs. This system could be particularly beneficial during any form of emerging infectious disease outbreaks, enhancing efficiency in a large and overcrowded ED during an epidemic, thereby helping to avoid unnecessary ED stays.

AUTHOR CONTRIBUTIONS

Kai-Wei Lin: Data curation; formal analysis; investigation; methodology; visualization; writing—original draft. Wan-Ching Lien: Conceptualization; data curation; formal analysis; investigation; methodology; resources; software; supervision; validation; writing—original draft; writing—review and editing.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

The study was approved by the institutional review board of the National Taiwan University Hospital (202107160RINC).