Situational Awareness in the ED

Author: Charlotte Davies /  Editor: Nikki Abela / Codes: CC4, CC5, CC7, CC8 / Published: 19/06/2018

Do you know what is going on with you and around you? Have you been in a situation where there are nine poorly patients in the resuscitation room, and you are the only Clinician looking after them? A new patient for another team comes in, and a new Clinician arrives and demands your help and doesn’t understand why you can’t be with them. Why don’t they understand? Almost certainly, they have no situational awareness. How we think and how we make decisions is a fascinating and very important subject, and this brief blog post only really touches the surface of it. We make thousands of decisions every day without thinking about them.
Outside of work, do you walk into people whilst you’re head down reading RCEMLearning blogs? Did you walk into the riots because you didn’t notice them? Situational awareness is important in every situation.

We will look at the three levels of situational awareness: how we prioritise, think and how we make some decisions.

What is situational awareness?

“The perception of elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future.” (Endsley 1995)

“One’s ability to remain aware of everything that is happening at the same time and to integrate that sense of awareness into what one is doing at the moment” (Haines & Flateau, 1992).

Level One: Awareness

Level one of situational awareness is looking at the elements in the environment — collecting the basic data about the patient and situation. This includes things like basic observations, blood test results and knowing other members of the team are present, but also knowing that a fifth patient is due into your four bed resus room.

This will help prevent you becoming biased or blinkered in what you see. I see a lot of blinkering in the ED. The easiest ED-based example is you have a patient with atrial fibrilliation that started an hour ago (!! Speedy triage). They need electrical cardioversion, and have consented to that. Is that the right thing to do? If resus is empty and there’s no patients waiting then yes, it is. If resus is already doubled up, we’re 5 Nurses short, and have a four hour wait – maybe not. It’s a case of being aware of everything, and balancing the needs of the patient with the needs of the department.
Another common ED example is everyone ignoring the crash buzzer because they need to get those ’emergency antibiotics’ in.

To make sure you get all the information you need to make an excellent decision, it might be useful to ‘scan & search’, pay attention, expect the unexpected and share the mental model considering:
Patient: Right patient, right time. What are the patient’s symptoms and observations?
Physical: Is it too noisy for me to do this? Can I control that? Are there too many distractions?
Human: Am I “HALT”? Hungry, Angry, Late or Lonely, Tired. What else is happening in the department? Did the “team huddle” earlier revealed we are 5 Nurses short tonight. Pilots use “I’m Safe” to identify any potential decision making problems before crunch point
Task: What is my goal? Is it to diagnose the patient, or to treat the numbers?
Time: Is now the right time to be doing this? How much time have I got?
Some of this information will be delivered or “pushed” to you, like the patient’s general appearance and the noise levels around you. Some information you will have to request or “pull”, like the observations. If you don’t push and pull all of the information, you run the risk of being biased in your information gathering approach.

Level Two: Comprehension

For level two awareness you begin to use the separate level 1 elements to understand what is happening. This might be:
 realising the monitor shows asystole because the leads have become unstuck.
 realising the respiratory rate has dropped because the fascia iliac block caused the pain stimulus to disappear, and the morphine has just kicked in.

Understanding the information requires a lot more cognitive (brain) function than just knowing the information. It is harder to learn this from textbooks alone. It needs people to recognise and interpret patterns, and see whether their patient fits.
It is during level two situational awareness that we might become cognitively biased, and need to employ strategies to stop this. Have you noticed that you suddenly see lots of cases of prostatitis after you’ve just had a teaching session on prostatitis? Or that the stroke team diagnose patients with strokes that you don’t think have had a stroke? These are all biases that we need to be aware of.

How do you avoid being biased?

  • We often use ‘sharing the mental model’ when talking about human factors. By this we mean tell the team what you think might be happening. If you list your differentials, it shows to them you have been thinking and helps avoid bias. A time-out or cognitive stop point can give you more time, and enable you to:
    – Consider alternatives
    – List your differential diagnoses
    – Look to see if anything does not fit
  • Minimise interruptions.
  • Make sure your system is set up for you to succeed, without the holes of the swiss cheese lining up. If you don’t encourage change, things will never improve. Marginal gains make big differences – small steps at a time.
    – Encourage accountability
    – Change systematic factors
    – Encourage improvement
  • Training
    – Practice high risk moments
    – Simulation
  • Cognitive Unloading

Cognitive Unloading

So what is cognitive unloading? I think this is one of the most useful aids to decision making – freeing up non-essential use of your brain power, so you can get on with the essentials!

Memory is divided in to three areas: sensory memory, working memory and long-term memory. Sensory information is only stored very briefly (0.5 to 2 seconds), and we have very little conscious control over it. Our conscious awareness is where information is transiently stored and processed. It can be thought of as a mental workspace that we can use to store important information in the
course of our current activity. We only use a fraction of the storage available. It contains all the information we have acquired and
stored over our whole lives, including our experiences, knowledge, and how to perform tasks. Try to remember this series of numbers, then repeat it back immediately without looking;

5 1 3 6 8 4

Now try to do the same thing – but before repeating it back, recite your own phone number, and then hold your breath for 20 seconds.

Why do you think it was more difficult the second time? Working memory is limited in capacity and duration. If distracted, or interrupted, and we switch our attention, we may lose the information in this memory store as we replace it with the new information. Cognitive load refers to the total amount of mental effort being used in the working memory, or your mental workload The “cognitive load” or “total working memory load” is the sum of intrinsic cognitive load and the extraneous cognitive load. In a medical workplace, to make a diagnosis a practitioner needs to process and integrate information that is retrieved from multiple sources, e.g. the patient, notes, blood results, previous experiences etc. If too much information or too many tasks are given simultaneously, you may not
be able to retain and process all the information; this is known as cognitive overload or maximum bandwith.

There are many ways you can “cognitively unload” and in the emergency department, where lots of things use up your cognitive power, this is always recommended. Things like checklists, prompt cards, resource files, guidelines and algorithms help, as does sharing the mental model.

Level 3 – Projection

The highest level of situational awareness is to predict the likely course. Your patients can notice this higher level of skill too – ‘I’m just waiting for your blood tests, but I expect they would be normal and you can go home’. More significant examples might be:
– Nursing staff getting the difficult airway trolley out in a failed intubation.
– The foundation doctor booking an intensive care bed.

This highest level of situational awareness is important in allowing members of the team to be proactive rather than reactive, and it requires everyone to ask “what if”. It should be listened too. You need to make sure that you project your thoughts, but also truly make sure the rest of the team has understood and ‘heard’ what you are saying. If you think of the Elaine Bromiley case, there was projection as the difficult airway kit was retrieved, but the message was not heard.

In Summary

Some people find it useful to “listen to their GUT” when thinking about situational awareness, and make sure you project from level one to level three. You might find this checklist useful in helping you to cognitively unload.

Gather Information

• scan & search
• pay attention, avoid fixation error
• remain watchful, expect the unexpected
• share the mental model

Understand the Information

• Pattern recognition, interpretation & evaluation
• Compare to what you know & what you expect
• Critique it, consider the integrity of the information
• Diagnose it, what does it mean?

Think Ahead

• Extrapolate & project beyond the ‘now’
• Ask “what if?” and ‘be ahead of the curve’

Further Reading

Prioritisation in the ED
Teaching Situational Awareness


  1. Adeel Ahmad Chaudhary says:

    Very useful post. Thanks

  2. Laith Mohammed Ridha Ali Al-Kassab says:

    It will change my way of handling cases.

  3. Kalakoti says:

    A nice and useful concept. Thanks a lot.

  4. Quraitulain Fatima Zaidi says:

    Very useful information. Thank you

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