Azmat Husain, MD: Role Awareness and Communication in the Emergency Department

In Part 3 of a 4-part interview with MD Magazine, Azmat Husain, MD, the senior vice president of clinical operations and chief medical officer of American Academic Health System, at Hahnemann University Hospital, spoke about how important it is for staff to know their roles in the emergency department, and how vital it is to have each member working to the top of their certifications.

Husain also addressed the best ways to prepare the hospital's physicians for life after residency, and how Hahnemann takes advantage of the educational tools it has at its disposal to inform its staff of their roles and responsibilities. He also discussed the importance of communication between staff members and how improving the triage system and zone structure can improve the workflow of the emergency department as a whole.

Watch the previous installment, Part 2 of the interview, here.Watch the next installment, Part 4 of the interview, here.

MD Magazine: In an environment like the emergency department, just how important is it that everyone knows their roles? How do you keep everyone focused on their responsibilities?

Azmat Husain, MD, senior vice president of clinical operations and chief medical officer, American Academic Health System:

That is critical in many ways, and that is life-saving, for everybody to be aware entirely what their roles are in a given scenario. What's great is, being in a teaching institution like we are, the residents and attendings and physicians, they actually simulate it.

There is a simulation lab that the residents and the physicians will go to because it's hard to speak to every scenario that's going to come in. When really, in the simulation lab, we have these high-end mannequins that are controlled—their heartbeat and everything—and put into different scenarios and, literally, what you're simulating is: what is your role in this scenario, in this position? Somebody will be a mock nurse, somebody will be your mock physician, somebody will be somebody else, and really, when you have moments to save somebody, you, in the back your mind, can't be so worried about what somebody else's role is. You really have to be very fixated on your role.

When I'm the attending physician on a trauma patient, I have that I have the head of the bed. I'm the emergency department physician, I have the head of the bed. I have to manage that patient’s airway, I have to get a breathing tube in, and the trauma surgeon needs to be down below the head and worried about if there is a gunshot wound to the chest into the abdomen. If he's worried about me putting the airway in, and I'm worried about him controlling that, then we potentially may have lost that patient. It is absolutely critical that we do that.

I really like that the way modern emergency medicine academic practices are going, with really incorporating simulation a lot. To be able to kind of go through these scenarios, test it out, and then you videotape it and you're able to see yourself in it—it's a great educational tool.

Myself, I'm 4 years out of residency, so I'm so kind of closer to my residency years. I feel strongly that the best teaching program is the best clinical program. If I'm a resident, I want to, when I step into the real world so to say, outside of residency—I want to make sure I've learned in a best-practice environment. I want to learn, I want to make sure that not only I can I just go work somewhere, but I can come and contribute. I can contribute to the process improvement of a department, I can contribute to the betterment of that community's emergency department. I think the 2 go absolutely hand-in-hand, in regard to the best clinical care and the most efficient care, which I think completely augments and supports great teaching, as well. That's the only way you learn.

You want your physicians, providers, and staff, to the best you can, working to the top of their certification. That's what you would want to optimize. That also leads to kind of a competent and satisfied staff member. If I'm a nurse who's doing the work of a nursing assistant, then I may not enjoy that. I'm not going to live up to that. If I'm a nurse practitioner who's doing work of a nurse, and all the way around [I need to work to my highest certification]. This is actually very well proven, as to what an appropriate scenario for a nurse practitioner and physician assistant.

At the same time, you don't want anybody working above their scope, either, and I think that's where the challenge comes in. That's why that when we go back to communication—it's so key. If you have a quick triage and the nurse spends moments with the patient to determine if they’re critical or not, then it goes to a nurse practitioner or physician assistant, who then determines whether they can get a nurse practitioner to continue this or should a physician—does this require a physician’s level of care? Really, you allow the nurse practitioner to bifurcate the patient. Is this above my comfort level or scope, or not?

Even beyond that, ultimately, every patient in the emergency department is the physician’s responsibility. Every patient that comes through, it is the physician's responsibility. That is on a micro-level, on a macro-level. On a micro-level, from shift to shift, from patient to patient, and then on a large scale, hey, educate everybody. Let's make sure they're involved in the processes, let's make sure they're aware. We're educating them, we're teaching them. My first 2 months here in my position, I was really working on putting in protocols and educating and providing teaching material for our nurse practitioners because we recognize that's so key.

The way you structure the emergency department in regard to zones is to allow acuity appropriate patients to be seen by the appropriate personnel. We have a nationally recognized triage system—1, 2, 3, 4, 5. We kind of bifurcate the threes, the middle patients, and the low-level of those patients, along with the fours and fives—low-acuity patients—so they can be seen appropriately by a nurse practitioner and physician’s assistant. But even if it's the lowest acuity patient, if a nurse practitioner ever has an issue, then the physician is there to back the provider up.

Transcript edited for clarity.