Quantitative Analysis of the Content of EMS Handoff of Critically Ill and Injured Patients to the Emergency Department

Exploring the Frameworks, Needs, and Barriers of Interprofessional Education and Simulation in Emergency Medicine

SUMMARY STATEMENT

This manuscript focuses on interprofessional education (IPE) using simulation and its use between emergency department and emergency medical services personnel. It explores the theoretical frameworks behind IPE and applies them to simulation-based emergency medical services education. There is a notable lack of research on the use of IPE using simulation between these 2 professions. The need for IPE using simulation as well as barriers and recommendations to remove the barriers are discussed.

Assessing North Texas Regional Trauma Handoffs: A Multicenter Mixed-Methods Needs Assessment

INTRODUCTION

Trauma video review of Emergency Medical Services (EMS) handoffs demonstrates frequent problems including interruptions and incomplete information transfer. This study aimed to perform a regional needs assessment of handoff perceptions and expectations to guide future standardization efforts.

METHODS

A multidisciplinary team of trauma providers through consensus building created an anonymous survey which was then distributed through the North Central Texas Trauma Regional Advisory Council and four regional level-1 trauma institutions. Qualitative data underwent content analysis; quantitative data are presented with descriptive statistics.

RESULTS

Survey responses (n = 249) were submitted by trauma nurses (38%), EMS (24%), emergency physicians (14%), and trauma physicians (13%). Median overall handoff quality was rated well (4, scale 1-5) despite some variability between hospitals (3, scale 1-5). The top five most important handoff details were the same for both stable and unstable patients: primary mechanism, blood pressure, heart rate, Glasgow Coma Scale, and location of injuries. While providers felt neutral about the data order, the vast majority supported immediate bed transfer and primary survey in unstable patients. The majority of receiving providers report interrupting handoff at least once (78%); and 66% of EMS clinicians found interruptions disruptive. Content analysis revealed top priority categories for improvement: environment, communication, information relayed, team dynamics, and flow of care.

CONCLUSION

Although our data demonstrated satisfaction and concordance with respect to the EMS handoff, 84% of EMS clinicians reported some to high amounts of variability across institutions. Gaps in the development of standardized handoffs identified include exposure, education, and enforcement of these protocols.

A Video-Based Study of Emergency Medical Services Handoffs to a Pediatric Emergency Department

BACKGROUND

Emergency medical services (EMS) to emergency department (ED) handoffs are important moments in patient care, but patient information is communicated inconsistently.

OBJECTIVE

The aim of this study was to describe the duration, completeness, and communication patterns of patient handoffs from EMS to pediatric ED clinicians.

METHODS

We conducted a video-based, prospective study in the resuscitation suite of an academic pediatric ED. All patients 25 years and younger transported via ground EMS from the scene were eligible. We completed a structured video review to assess frequency of transmission of handoff elements, handoff duration, and communication patterns. We compared outcomes between medical and trauma activations.

RESULTS

We included 156 of 164 eligible patient encounters from January to June 2022. Mean (SD) handoff duration was 76 (39) seconds. Chief symptom and mechanism of injury were included in 96% of handoffs. Most EMS clinicians communicated prehospital interventions (73%) and physical examination findings (85%). However, vital signs were reported for fewer than one-third of patients. EMS clinicians were more likely to communicate prehospital interventions and vital signs for medical compared with trauma activations (p < 0.05). Communication challenges between EMS clinicians and the ED were common; ED clinicians interrupted EMS or requested information already communicated by EMS in nearly one-half of handoffs.

CONCLUSIONS

EMS to pediatric ED handoffs take longer than recommended and frequently lack important patient information. ED clinicians engage in communication patterns that may hinder organized, efficient, and complete handoff. This study highlights the need for standardizing EMS handoff and ED clinician education regarding communication strategies to ensure active listening during EMS handoff.

Improving Emergency Medicine Clinician Awareness of Prehospital-Administered Medications

Background/problem: Information transfer between emergency medical services (EMS) and emergency medicine (EM) is at high risk for omissions and errors. EM awareness of prehospital medication administration affects patient management and medication error. In April 2020, we surveyed emergency physicians and emergency department nurse practitioners (NPs) and physician assistants (PAs) regarding the EMS handoff process. Emergency physicians and NPs/PAs endorsed knowing what medications were given, or having received direct verbal handoff from EMS "Often" or "Always" only 20% of the time (n = 71), identifying a need to improve the written handoff process. To assess rates of medication error due to lack of awareness of prehospital administered medications, we measured glucocorticoid redosing in the emergency department (ED) following prehospital dexamethasone administration. In 2020, glucocorticoids were redosed 30% of the time, and our aim was to reduce glucocorticoid redosing to 10% by June 2022. Intervention: We developed and implemented a system innovation where prehospital-administered medications documented in a nursing flowsheet during verbal handoff are pulled directly into the triage note where they are more likely to be reviewed by receiving EM clinicians. Results: Shewhart p-charts were used to evaluate for statistical process change in the process measure of triage note documentation of prehospital medication administration and the outcome measure of glucocorticoid redosing. While the frequency of prehospital dexamethasone administration in the triage note increased, no statistical process change outcome measure of glucocorticoid redosing was observed. However, on repeat survey of EM clinicians in July 2022, 50% now indicated they were aware of prehospital medication administration "Often" or "Always" (n = 61, p = 0.003), 87% maintained they use the triage note as the main source of information regarding prehospital medication administration, and 81% "Always" review the triage note. Conclusions: Innovations that improve accessibility of written documentation of prehospital medication administration were associated with improved subjective assessment of EM clinician awareness of prehospital medications, but not the outcome measure of medication error. Effective error reduction likely requires better system integration between prehospital and EM records.

Assessment of Gender Bias During Paramedic-Physician Handoffs

Objective Gender bias against female physicians has been frequently demonstrated and associated with negative feelings toward their careers. Gender bias has also been demonstrated in prehospital clinical care. However, potential gender bias during paramedic-physician handoffs has not been studied. This study aimed to identify gender bias during interactions between prehospital personnel and emergency physicians at the time of patient handoff. Methods An observational study was conducted at an urban academic emergency department. Observers were trained to record information from paramedic-physician handoffs but were blind to the nature of the study. The primary outcome was to whom paramedics initially directed the focus of their handoff report based on physician gender, with secondary outcomes of to whom paramedics directed most of their report and whether they asked about further questions based on physician gender. Results There were 784 observed handoffs. There was no significant association between the gender of the physician and which physician received first attention (χ2 {1, N = 782} = 0.9736, p = 0.3238) or majority attention (χ2 {1, N = 780} = 1.9414, p = 0.1635). Paramedics were more likely to ask questions to male attendings than female attendings (χ2 {1, N = 784} = 4.4319, p = 0.0353). Conclusion We identified limited differences in communication based on gender between paramedics and physicians during emergency department patient handoffs.

Violence against nurses in the emergency department: an observational study

OBJECTIVE

This study aimed to evaluate the number and risk factors of violent events encountered in the emergency department. An observation grid was developed following interviews with emergency department staff to target the most pertinent information to collect in a prospective study design.

DESIGN

Observational study.

SETTING

Emergency department of a tertiary hospital in France.

OUTCOME MEASURES

Number of violent events occurring during a single shift, recorded over 6 months by two observers. Information collected included time and date of incident; number of male/female staff; number of patients and accompaniers present in the service and the waiting room and length of staff debriefing. Perpetrator, victim and patient information were collected. Victims were followed-up 72 hours later.

RESULTS

Eighty-two periods were observed between November 2015 and April 2016 recording 35 violent incidents affecting 37 perpetrators and 48 victims, equally distributed over the days of the week and months of the year. The median interval until violence was 0 [0-96] min from entry. Eight (23%) events were officially reported, with two (6%) resulting in charges being pressed. No risk factors were significantly associated with violent incidents in multivariate analysis, although there was a tendency towards significance for fewer senior female doctors present (p=0.0787) and a resulting longer debriefing session (p=0.0712).

CONCLUSIONS

We confirm the high rate of violence in the emergency department and poor level of official reporting. Strategies should be implemented to anticipate and reduce incidence and encourage reporting by affected staff.

TRIAL REGISTRATION NUMBER

NCT02116439.

Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care

Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.

Using Trauma Video Review to Assess EMS Handoff and Trauma Team Non-Technical Skills

OBJECTIVE

Handoffs by emergency medical services (EMS) personnel suffer from poor structure, inattention, and interruptions. The relationship between the quality of EMS communication and the non-technical performance of trauma teams remains unknown.

METHODS

We analyzed 3 months of trauma resuscitation videos (highest acuity activations or patients with an Injury Severity Score [ISS] of ≥15). Handoffs were scored using the mechanism-injury-signs-treatment (MIST) framework for completeness (0-20), efficiency (category jumps), interruptions, and timeliness. Trauma team non-technical performance was scored using the Trauma Non-Technical Skills (T-NOTECHS) scale (5-15).

RESULTS

We analyzed 99 videos. Handoffs lasted a median of 62 seconds [IQR: 43-74], scored 11 [10-13] for completeness, and had 2 [1-3] interruptions. Most interruptions were verbal (85.2%) and caused by the trauma team (64.9%). Most handoffs (92%) were efficient with 2 or fewer jumps. Patient transfer during handoff occurred in 53.5% of the videos; EMS providers giving handoff helped transfer in 69.8% of the Primary surveys began during handoff in 42.4% of the videos. Resuscitation teams who scored in the top-quartile on the T-NOTECHS (>11) had higher MIST scores than teams in lower quartiles (13 [11.25-14.75] vs. 11 [10-13]; p < .01). There were no significant differences in ISS, efficiency, timeliness, or interruptions between top- and lower-quartile groups.

CONCLUSIONS

There is a relationship between EMS MIST completeness and high performance of non-technical skill by trauma teams. Trauma video review (TVR) can help identify modifiable behaviors to improve EMS handoff and resuscitation efforts and therefore trauma team performance.

Development of a checklist for auditing completion of patient report forms: A Delphi study

•

Information loss during the handover from Emergency Care Providers to hospital staff is common and has a significant impact on patient care.

•

Development of prehospital emergency care quality systems, such as checklists, has been limited in the African context

•

Using a Delphi survey we identify relevant South African-specific elements to improve the validity and generalisability of a patient report form checklist.

Introduction

Medical records are an integral part of patient care. Information loss during the handover from Emergency Care Providers to hospital staff is common and has a significant impact on patient care. Information loss can be prevented with medical documentation that is accurate, complete and contains the relevant information regarding patient management. Patient report Forms (PRF's) are used by Emergency Care Providers to record the details of their patient care and they form part of the patients’ medical records. Quality assuring of PRF's is required to determine if the required information has been recorded on the PRF. Checklists are one the means of quality assuring PRF, by comparing the points on the checklist to the content of the PRF.

Methods

An three-round Delphi survey was conducted with experts to determine the relevant information (data elements) required for the completion of a PRF including any additional South African – specific elements.

Results

Thirty-two experts participated in the Delphi survey, which identified 166 data elements for the check list and this was refined to a final 133 elements after collation by the researchers. A proposed checklist was developed.

Discussion

The Delphi process is a useful technique to develop a checklist. A checklist consisting of 133 total possible data elements to quality assure PRFs was designed. Further research regarding the use and reliability of the checklist is required.

Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT

Background

Intravenous thrombolysis and intra-arterial thrombectomy are proven emergency treatments for acute ischaemic stroke, but they require rapid delivery to selected patients within specialist services. National audit data have shown that treatment provision is suboptimal.

Objectives

The aims were to (1) determine the content, clinical effectiveness and day 90 cost-effectiveness of an enhanced paramedic assessment designed to facilitate thrombolysis delivery in hospital and (2) model thrombectomy service configuration options with optimal activity and cost-effectiveness informed by expert and public views.

Design

A mixed-methods approach was employed between 2014 and 2019. Systematic reviews examined enhanced paramedic roles and thrombectomy effectiveness. Professional and service user groups developed a thrombolysis-focused Paramedic Acute Stroke Treatment Assessment, which was evaluated in a pragmatic multicentre cluster randomised controlled trial and parallel process evaluation. Clinicians, patients, carers and the public were surveyed regarding thrombectomy service configuration. A decision tree was constructed from published data to estimate thrombectomy eligibility of the UK stroke population. A matching discrete-event simulation predicted patient benefits and financial consequences from increasing the number of centres.

Setting

The paramedic assessment trial was hosted by three regional ambulance services (in north-east England, north-west England and Wales) serving 15 hospitals.

Participants

A total of 103 health-care representatives and 20 public representatives assisted in the development of the paramedic assessment. The trial enrolled 1214 stroke patients within 4 hours of symptom onset. Thrombectomy service provision was informed by a Delphi exercise with 64 stroke specialists and neuroradiologists, and surveys of 147 patients and 105 public respondents.

Interventions

The paramedic assessment comprised additional pre-hospital information collection, structured hospital handover, practical assistance up to 15 minutes post handover, a pre-departure care checklist and clinician feedback.

Main outcome measures

The primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included day 90 health (poor status was a modified Rankin Scale score of > 2). Economic outputs reported the number of cases treated and cost-effectiveness using quality-adjusted life-years and Great British pounds.

Data sources

National registry data from the Sentinel Stroke National Audit Programme and the Scottish Stroke Care Audit were used.

Review methods

Systematic searches of electronic bibliographies were used to identify relevant literature. Study inclusion and data extraction processes were described using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results

The paramedic assessment trial found a clinically important but statistically non-significant reduction in thrombolysis among intervention patients, compared with standard care patients [197/500 (39.4%) vs. 319/714 (44.7%), respectively] (adjusted odds ratio 0.81, 95% confidence interval 0.61 to 1.08; p = 0.15). The rate of poor health outcomes was not significantly different, but was lower in the intervention group than in the standard care group [313/489 (64.0%) vs. 461/690 (66.8%), respectively] (adjusted odds ratio 0.86, 95% confidence interval 0.60 to 1.2; p = 0.39). There was no difference in the quality-adjusted life-years gained between the groups (0.005, 95% confidence interval –0.004 to 0.015), but total costs were significantly lower for patients in the intervention group than for those in the standard care group (–£1086, 95% confidence interval –£2236 to –£13). It has been estimated that, in the UK, 10,140–11,530 patients per year (i.e. 12% of stroke admissions) are eligible for thrombectomy. Meta-analysis of published data confirmed that thrombectomy-treated patients were significantly more likely to be functionally independent than patients receiving standard care (odds ratio 2.39, 95% confidence interval 1.88 to 3.04; n = 1841). Expert consensus and most public survey respondents favoured selective secondary transfer for accessing thrombectomy at regional neuroscience centres. The discrete-event simulation model suggested that six new English centres might generate 190 quality-adjusted life-years (95% confidence interval –6 to 399 quality-adjusted life-years) and a saving of £1,864,000 per year (95% confidence interval –£1,204,000 to £5,017,000 saving per year). The total mean thrombectomy cost up to 72 hours was £12,440, mostly attributable to the consumables. There was no significant cost difference between direct admission and secondary transfer (mean difference –£368, 95% confidence interval –£1016 to £279; p = 0.26).

Limitations

Evidence for paramedic assessment fidelity was limited and group allocation could not be masked. Thrombectomy surveys represented respondent views only. Simulation models assumed that populations were consistent with published meta-analyses, included limited parameters reflecting underlying data sets and did not consider the capital costs of setting up new services.

Conclusions

Paramedic assessment did not increase the proportion of patients receiving thrombolysis, but outcomes were consistent with improved cost-effectiveness at day 90, possibly reflecting better informed treatment decisions and/or adherence to clinical guidelines. However, the health difference was non-significant, small and short term. Approximately 12% of stroke patients are suitable for thrombectomy and widespread provision is likely to generate health and resource gains. Clinician and public views support secondary transfer to access treatment.

Future work

Further evaluation of emergency care pathways will determine whether or not enhanced paramedic assessment improves hospital guideline compliance. Validation of the simulation model post reconfiguration will improve precision and describe wider resource implications.

Trial registration

This trial is registered as ISRCTN12418919 and the systematic review protocols are registered as PROSPERO CRD42014010785 and PROSPERO CRD42015016649.

Funding

The project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 4. See the NIHR Journals Library website for further project information.

An Incomplete Medical Record: Transfer of Care From Emergency Medical Services to the Emergency Department

Background: Transition of care from Emergency Medical Services (EMS) to the Emergency Department (ED) represents an intersection at high risk for error. Minimal research has quantitatively examined data transfer at this point. In Pennsylvania, this handoff consists of a transfer-of-care form (TOC) provided by EMS to ED in addition to a verbal report. A prehospital patient care report (PCR) is later filed by EMS up to 72 hours after concluding care.

Objective: To evaluate the congruence between prehospital records provided at handoff and the final PCR found in the patient’s medical record. Our hypothesis was that there would be discrepancies between the TOC and final PCR.

Methods: A retrospective chart review was conducted comparing the TOC from a single EMS agency to the final PCR found in the electronic medical record. A convenience sample of 200 patients who received advanced life support transport over a one-month period were included. Metrics to assess the discrepancy between the reports included chief complaint, allergies, medications, systolic and diastolic blood pressure (SBP and DBP), pulse, respiratory rate (RR), Glasgow Coma Score (GCS), and prehospital treatment provided. The level of agreement between the two sources was compared using kappa statistics and concordance correlation coefficients (CCC) with 95% confidence intervals.

Results: Of the 200 encounters that met inclusion criteria, 72% had matching chief complaints between the TOC and PCR. Medications matched in 66% and allergies matched in 82%. Up to three BP, pulse, and RR readings were collected; only 30% of the third BP readings were available from the TOC, while 68% were available from the PCR. Comparing the three SBP values on the TOC to respective counterparts on the PCR showed a substantial correlation (all CCC >0.95). Pulse and DBP values had moderate-to-substantial correlation (CCC: 0.93, 0.94, 0.96 and 0.77, 0.92, 0.94 respectively). RR showed inconsistent correlation (CCC: 0.37, 0.84, 0.94). GCS showed a moderate correlation between the two forms (CCC: 0.81).

Conclusion: There were significant differences between the information transferred to the ED through the TOC compared to what was recorded in the PCR. Further evaluation of the TOC process is needed to improve accuracy.

Screening of community-dwelling older patients by the emergency medical services: An observational retrospective registry study

BACKGROUND

Inadequate nutrition, falls, and cognitive impairment are common problems among acutely ill older people and are associated with complicated and prolonged health problems and mortality.

OBJECTIVES

To assess if the emergency medical services can identify patients with nutritional risk, falls risk, and cognitive impairment by using simple screening tools and to assess the prevalence of risks and rate they are reported to the emergency department.

SETTING

The study was carried out in Espoo, Finland to patients over the age of 70 requiring non-urgent ambulance transfer to the emergency department.

OUTCOME MEASURES

A set of validated electronic screening tools was used to identify patients at nutritional risk, risk of falling and having cognitive impairment.

MAIN RESULTS

A total of 488 (8%) out of 5792 patients were screened. Of the patients 60%, (n = 292) had at least one risk: 17% (n = 81) had nutritional risk, 43% (n = 209) falls risk, and 28% (n = 137) cognitive impairment. Twenty-two (5%) were screened positive in all three categories. The observed risk was reported to the emergency department staff in 59% (n = 173) of the patients.

CONCLUSION

The emergency medical services can be used in preventive health care to identify patients having nutritional risk, falls risk, or cognitive impairment.

Effect of an Enhanced Paramedic Acute Stroke Treatment Assessment on Thrombolysis Delivery During Emergency Stroke Care: A Cluster Randomized Clinical Trial

Question

Can hospital stroke thrombolysis treatment rates be increased by an enhanced paramedic assessment that includes additional prehospital information collection, a structured hospital handover, practical assistance after handover, a predeparture care checklist, and clinician feedback?

Findings

In this cluster randomized clinical trial, fewer patients in the intervention group (39.4%) received thrombolysis vs those in the standard care group (44.7%), but there were fewer poor health outcomes (disability or death) after 90 days (intervention group, 64.0% vs standard care group, 66.8%). The results were not statistically significant.

Meaning

This study found that the enhanced paramedic assessment should not be used to increase thrombolysis volume but may influence the quality of treatment decisions.

Importance

Rapid thrombolysis treatment for acute ischemic stroke reduces disability among patients who are carefully selected, but service delivery is challenging.

Objective

To determine whether an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) intervention increased hospital thrombolysis rates.

Design, Setting, and Participants

This multicenter, cluster randomized clinical trial took place between December 2015 and July 2018 in 3 ambulance services and 15 hospitals. Clusters were paramedics based within ambulance stations prerandomized to PASTA or standard care. Patients attended by study paramedics were enrolled after admission if a hospital specialist confirmed a stroke and paramedic assessment started within 4 hours of onset. Allocation to PASTA or standard care reflected the attending paramedic’s randomization status.

Interventions

The PASTA intervention included additional prehospital information collection, a structured hospital handover, practical assistance up to 15 minutes after handover, a predeparture care checklist, and clinician feedback. Standard care reflected national guidelines.

Main Outcomes and Measures

Primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included time intervals and day 90 health (with poor status defined as a modified Rankin Score >2, to represent dependency or death).

Results

A total of 11 478 patients were screened following ambulance transportation; 1391 were eligible and approached, but 177 did not consent. Of 1214 patients enrolled (mean [SD] age, 74.7 [13.2] years; 590 women [48.6%]), 500 were assessed by 242 paramedics trained in the PASTA intervention and 714 were assessed by 355 paramedics continuing with standard care. The paramedics trained in the PASTA intervention took a mean of 13.4 (95% CI, 9.4-17.4) minutes longer (P < .001) to complete patient care episodes. There was less thrombolysis among the patients in the PASTA group, but this was not significant (PASTA group, 197 of 500 patients [39.4%] vs the standard care group, 319 of 714 patients [44.7%]; adjusted odds ratio, 0.81 [95% CI, 0.61-1.08]; P = .15). Time from a paramedic on scene to thrombolysis was a mean of 8.5 minutes longer in the PASTA group (98.1 [37.6] minutes) vs the standard care group (89.4 [31.1] minutes; P = .01). Poor health outcomes did not differ significantly but occurred less often among patients in the PASTA group (313 of 489 patients [64.0%]) vs the standard care group (461 of 690 patients [66.8%]; adjusted odds ratio, 0.86 [95% CI, 0.60-1.20]; P = .39).

Conclusions and Relevance

An enhanced paramedic assessment did not facilitate thrombolysis delivery. The unexpected combination of thrombolysis and health outcomes suggests possible alternative influences on treatment decisions by the intervention, requiring further evaluation.

Trial Registration

ISRCTN Registry Identifier: ISRCTN12418919

Eastern association for the surgery of trauma - quality, patient safety, and outcomes committee - transitions of care: healthcare handoffs in trauma

BACKGROUND

Handoffs are defined as the transfer of patient information, professional responsibility, and accountability between caregivers. This work aims to clarify the current state of transitions of care related to the management of trauma patients.

METHODS

A PubMed database and web search were performed for articles published between 2000 and 2020 related to handoffs and transitions of care. The key search terms used were: handoff(s), handoff(s) AND healthcare, and handoff(s) AND trauma. A total of 55 studies were included in qualitative synthesis.

RESULTS

This systematic review explores the current state of healthcare handoffs for trauma patients. Factors found to impact successful handoffs included process standardization, team member accountability, effective communication, and the incorporation of culture. This review was limited by the small number of prospective randomized studies available on the topic.

CONCLUSION

Handoffs in trauma care have been studied and should be utilized in the context of published experience and practice. Standardization when applied with accountability has proven benefit to reduce communication errors during these transfers of care.

Clinical handover from emergency medical services to the trauma team: A gap analysis

OBJECTIVES

There has been limited evaluation of handover from emergency medical services (EMS) to the trauma team. We sought to characterize these handover practices to identify areas of improvement and determine if handover standardization might be beneficial for trauma team performance.

METHODS

Data were prospectively collected over a nine-week period by a trained observer at a Canadian level one trauma centre. A randomized scheduled was used to capture a representative breadth of handovers. Data collected included outcome measures such as duration of handover, structure of the handover, and information shared, process measures such as questions and interruptions from the trauma team, and perceptions of the handover from nurses, trauma team leaders and EMS according to a bidirectional Likert scale.

RESULTS

79 formal verbal handovers were observed. Information was often missing regarding airway (present 22%), breathing (54%), medications (59%), and allergies (54%). Handover structure lacked consistency beyond the order of identification and mechanism of injury. Of all questions asked, 35% were questioning previously given information. The majority of handovers (61%) involved parallel conversations between team members while EMS was speaking. There was a statistically significant disparity between the self-evaluation of EMS handovers and the perceived quality determined by nurses and trauma team leaders.

CONCLUSIONS

We have identified the need to standardize handover due to poor information content, a lack of structure and active listening, information repetition, and discordant expectations between team members. These data will guide the development of a co-constructed framework integrating the perspectives of all team members.

Impact of a Standardized Patient Hand-off Tool on Communication between Emergency Medical Services Personnel and Emergency Department Staff

INTRODUCTION

Handoff communication between Emergency Medical Services (EMS) and Emergency Department (ED) staff is critical to ensure quality patient care. In January 2016, the Southwest Texas Regional Advisory Council (STRAC) implemented MIST (Mechanism, Injuries, vital Signs, Treatments), a standardized EMS to ED handoff tool. The En route Care Research Center conducted a Pre-MIST implementation survey of ED staff in December 2015 and a Post-MIST follow-up survey in July 2017 to determine the impact of the MIST handoff tool on the perceived quality of transmission of pertinent patient information and in the overall handoff experience.

METHODS

We administered a nine-item Likert scale questionnaire to Brooke Army Military Medical Center (BAMC) ED providers and nurses before and after implementation of MIST. The questionnaire captured perceived competence and satisfaction with handoff communication (Cronbach's alpha 0.73). We analyzed responses for the total sample and by occupation (providers and nurses), and we calculated odds ratios to determine items that may be most predictive of a positive handoff experience from the perspective of the ED staff. We performed chi-square tests and reported data as percentages.

RESULTS

Total respondents Pre- and Post-MIST were 128 (62%) nurses and 80 (38%) providers (MDs, DOs, and PAs). Following the implementation of MIST, more respondents reported that they were "informed of prehospital treatments" (p < 0.001), that "Red/Blue Trauma Alert Criteria were conveyed" (p < 0.001), and that the "time to give the report was sufficient to convey pertinent information" (p < 0.001). Nurses more frequently reported that "Red/Blue Trauma Alert Criteria were conveyed" post-MIST (p < 0.01). Providers more frequently reported that "Assessment findings were conveyed" (p < 0.05), that they 'interrupted the report for clarification" (p < 0.04), that "time to give the report was sufficient to convey pertinent information" (p < 0.001) and that they "felt positive about the overall handoff experience" (p < 0.03) Post-MIST. Overall satisfaction with the handoff was associated with frequently being informed of prehospital treatments (OR 5.5; 2.1-14.4) and frequently receiving a copy of the prehospital record (OR 2.9; 1.1-7.2).

CONCLUSIONS

These data demonstrate that providers and nurses reported an improvement in the handoff experience Post-MIST. This study supports the use of a standardized handoff tool at this critical step in patient care.

Barriers to effective EMS to emergency department information transfer at patient handover: A systematic review

BACKGROUND

Handovers of care are necessary, yet a vulnerable time for patient safety. They can either reduce the risk of medical error during transitions of care or cause direct medical or financial harm to patients due to poor communication.

OBJECTIVE

To review (1) observational studies that quantify the frequency of transfer of specific data points or clinician retention of information provided in prehospital verbal handoff to assess the state of EMS-to-ED handoffs; (2) surveys and interviews of prehospital and ED staff perceptions of the handover process and any perceived barriers to optimal handover found therein; (3) interventional studies that have aimed to improve the quality of EMS to ED handoffs.

METHODS

A systematic review of the literature was performed using Pubmed, Web of Science, Google Scholar, and Cochrane Database of Systematic Reviews and by hand-searching references of relevant articles. Articles were selected that focused on verbal and/or written handover of patient care from EMS to ED providers and that addressed the above goals. Qualitative data was extracted from the articles and assessed using thematic synthesis.

RESULTS

78 articles were identified for full text review, 60 of which met inclusion criteria. Four categories of barriers emerged on thematic synthesis: educational, operational, cultural, and cognitive. Within these categories, 12 initial descriptive themes and 9 suggested interventions were identified.

CONCLUSIONS

Descriptive themes of disrespect & disinterest, environmental factors, redundancy, poor recall, conflicting goals and perspectives, technological issues, information degradation, information loss, lack of standardization, lack of training, delays, and lack of feedback were identified as barriers to effective EMS to ED handovers. Three categories of interventions were identified across the included interventional studies, namely technological, educational, and changes to cultural customs.

Critical Communication: A Cross-sectional Study of Signout at the Prehospital and Hospital Interface

Introduction Miscommunication during patient handoff contributes to an estimated 80% of serious medical errors and, consequently, plays a key role in the estimated five million excess deaths annually from poor quality of care in low- and middle-income countries (LMICs). Objective The objective of this study was to assess signout communication during patient handoffs between prehospital personnel and hospital staff. Methods This is a cross-sectional study, with a convenience sample of 931 interfacility transfers for pregnant women across four states from November 7 to December 13, 2016. A complete signout, as defined for this study, contains all necessary signout elements for patient care exchanged verbally or in written form between an emergency medical technician (EMT) and a physician or nurse. Results Enrollment of 786 cases from 931 interfacility transfers resulted in 1572 opportunities for signout. EMTs and a physician or nurse signed out in 1549 cases (98.5%). Signout contained all elements in 135 cases (8.6%). The mean percentage of signout elements included was 45.2% (95% CI, 43.9-46.6). Physician involvement was correlated with a higher mean percent (63.4% [95% CI, 62-64.8]) compared to nurse involvement (23.6% [95% CI, 22.5-24.8]). With respect to the frequency of signout communication, 63.1% of EMTs reported often or always giving signout, and 60.5% reported often or always giving signout; they reported feeling moderately to very comfortable with signout (73.7%) and 34.1% requested further training. Conclusions Physicians, nurses, and the EMTs conducted signout 99% of the time but often fell short of including all elements required for optimal patient care. Interventions aimed at improving the quality of patient care must include strengthening signout communication.

Activation to Arrival: Transition and Handoff from Emergency Medical Services to Emergency Departments

The burden of neurologic disease in the United States continues to increase due to a growing older population, increased life expectancy, and improved mortality after cancer and cardiac disease. Emergency medical services (EMS) providers are responding to more patients with stroke, traumatic neurologic injury, neuromuscular weakness, seizure, and spontaneous cardiac arrest. Efficient prehospital care and triage to facilities with specialized services improve outcomes. Effective handoff from EMS to an emergency department ensures continuity of care and patient safety. Although advancements in prehospital cardiopulmonary resuscitation have increased rates of return to spontaneous circulation, a large proportion of patients sustain neurologic injury.

Higher LRINEC Scores and Escalation of Anesthesia Care in Necrotizing Soft Tissue Infection

BACKGROUND

The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score may distinguish necrotizing soft tissue infection (NSTI) from non-NSTI. The association of higher preoperative LRINEC scores with escalations of intraoperative anesthesia care in NSTI is unknown and may be useful in communicating illness severity during patient handoffs.

MATERIALS AND METHODS

We conducted a retrospective cohort study of first operative debridement for suspected NSTI in a single referral center from 2013 to 2016. We assessed the association between LRINEC score and vasopressors, blood products, crystalloid, invasive monitoring, and minutes of operative and anesthesia care.

RESULTS

We captured 332 patients undergoing their first operative debridement for suspected NSTI. For every 1-point higher LRINEC score, there was a higher risk of norepinephrine and vasopressin use (relative risk [RR] = 18%, 95% confidence interval [CI] [10%, 26%] and [10%, 27%], respectively), packed red blood cell use (RR = 28% [95% CI 13%, 45%]), and additional crystalloid (17.57 mL/h [95% CI 0.37, 34.76]). Each additional LRINEC point was associated with longer anesthesia (3.42 min, 95% CI 0.94, 5.91) and operative times (2.35 min, 95% CI 0.29, 4.40) and a higher risk of receiving invasive arterial monitoring (RR 1.11, 95% CI 1.05, 1.18). The negative predictive value for an LRINEC score < 6 was > 90% for use of vasopressors and packed red blood cells.

CONCLUSIONS

Preoperative LRINEC scores were associated with escalations in intraoperative care in patients with NSTI. A low score may predict patients unlikely to require vasopressors or blood and may be useful in standardized handoff tools for patients with NSTI.

Health Information Exchange in Emergency Medical Services

BACKGROUND

The Office of the National Coordinator for Health Information Technology has outlined the benefits of health information exchange in emergency medical services (EMSs) according to the SAFR model-search, alert, file, and reconcile-developed in collaboration with the California Emergency Medical Services Authority.

OBJECTIVE

This scoping review aims to identify and characterize progress toward the adoption of prehospital health information exchange, as reported in the peer-reviewed literature.

METHODS

A structured review of literature in MEDLINE-indexed journals was conducted using the "Electronic Health Records" topic-specific query, the "Emergency Medical Services" Medical Subject Headings descriptor, and a prehospital identifier.

RESULTS

Our initial search yielded 368 nonduplicative, English-language articles; 131 articles underwent full-text review and 11 were selected for analysis according to pre-established inclusion criteria. Original research was thematically grouped according to the SAFR model.

CONCLUSION

Within isolated systems, there has been limited progress toward the adoption of prehospital health information exchange. Interoperability, accurate match algorithms, security, and wireless connectivity have been identified as potential barriers to adoption. Additional research is required to evaluate the role of health information exchange within EMSs.

Videographic Assessment of the Quality of EMS to ED Handoff Communication During Pediatric Resuscitations

BACKGROUND

The National Association of Emergency Medical Services (EMS) Physicians emphasizes the importance of high quality communication between EMS providers and emergency department (ED) staff for providing safe, effective care. The Joint Commission has identified ineffective handoff communication as a contributing factor in 80% of serious medical errors. The quality of handoff communication from EMS to ED teams for critically ill pediatric patients needs further exploration.

OBJECTIVE

This study assessed the quality of handoff communication between EMS and ED staff during pediatric medical resuscitations.

METHODS/DESIGN

We conducted a retrospective review of video recordings of pediatric patients who required critical care ("resuscitation") in the ED between January 2014 and February 2016 at a Level 1 pediatric trauma center. Handoff quality between EMS and emergency department teams was assessed for completeness, timeliness, and efficiency. Institutional review board approval was obtained.

RESULTS

Sixty-eight resuscitations were reviewed; 28% presented in cardiac arrest, requiring cardiopulmonary resuscitation (CPR). Completeness of information communicated was variable and included chief complaint (88%), prehospital interventions (81%), physical exam findings (63%), medical history (59%), age (56%), and weight (20%). Completeness of specific vital sign reporting included: respiratory rate (53%), heart rate (43%), oxygen saturation (39%), and blood pressure (31%). Timeliness of communication included median patient handoff and report times of 50 seconds [IQR 30,74] and 108 seconds [IQR 62,252], respectively. Inefficient communication occurred in 87% of handoffs, including interruptions by ED staff (51%), questions from the ED physician team leader asking for information already communicated (40%), and questions by ED physician team leader requesting information not yet communicated (65%). When comparing non-CPR to CPR cases, only timeliness of patient handoff was significantly different for those patients receiving prehospital CPR.

CONCLUSION

Handoff communication between EMS and ED teams during pediatric resuscitation was frequently incomplete and inefficient. Future educational and quality improvement interventions could aim to improve the quality of handoff communication for this patient population.

Communication Strategies for Better Care of Older Individuals in the Emergency Department

The need for teamwork and communication among emergency department staff is central to excellent health care and of particular importance for the complex older adult population. Communication can decrease error, enhance safety, and improve throughput. Communication strategies both among multiple health care professionals, and between professionals and family and/or patients can improve care for older adults in the unique emergency department environment.

Receiving Providers' Perceptions on Information Transmission During Interfacility Transfers to General Pediatric Floors

BACKGROUND

Pediatric patients can present to a medical facility and subsequently be transferred to a different hospital for definitive care. Interfacility transfers require a provider handoff across facilities, posing risks that may affect patient outcomes.

OBJECTIVES

The goal of this study was to describe the thoroughness of information transmission between providers during interfacility transfers, to describe perceived errors in care at the posttransfer facility, and to identify potential associations between thoroughness of information transmission and perceived errors in care.

METHODS

We performed an exploratory prospective cohort study on communication practices and patient outcomes during interfacility transfers to general pediatric floors. Data were collected from provider surveys and chart review. Descriptive statistics were used to summarize survey responses. Logistic regression was used to analyze the association of communication deficits with odds of having a perceived error in care.

RESULTS

A total of 633 patient transfers were reviewed; 218 transport command physician surveys and 217 frontline provider surveys were completed. Transport command physicians reported higher proportions of key elements being included in the verbal handoff compared with frontline providers. The written key element transmitted with the lowest frequency was a summary document (65.2%), and 13% of transfers had at least 1 perceived error in care. Transfers with many deficits were associated with higher odds of having a perceived error in care.

CONCLUSIONS

Information transmission during pediatric transfers is perceived to be inconsistently complete. Deficits in the verbal and written information transmission are associated with odds of having a perceived error in care.