Emergency Care Handover (ECHO study) across care boundaries: the need for joint decision making and consideration of psychosocial history

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.

Assessing the quality of patient handovers between ambulance services and emergency department – development and validation of the emergency department human factors in handover tool

Background

Patient handover between prehospital care and the emergency department plays a key role in patient safety. Therefore, we aimed to create a validated tool for measuring quality of communication and interprofessional relations during handover in this specific setting.

Methods

Based on a theoretical framework a comprehensive item pool on information transfer and human factors in emergency department handovers was created and refined in a modified Delphi survey involving clinical experts. Based on a pre-test, items were again revised. The resulting Emergency Department Human Factors in Handover tool (ED-HFH) was validated in a field test at the emergency department of a German university hospital from July to December 2017. The ED-HFH was completed by emergency department and ambulance service staff participating in handovers and by an external observer. Description of item characteristics, exploratory factor analysis, analyses on internal consistency and interrater reliability by intraclass-correlation. Construct validity was analysed by correlation with an overall rating on quality of the handover.

Results

The draft of the ED-HFH contained 24 items, 90 of 102 eligible staff members participated in the field test completing 133 questionnaires on 38 observed handovers. Four items were deleted after analysis of item characteristics. Factor analysis supported a single factor explaining 39% of variance in the items. Therefore, a sum-score was calculated with a possible range between 14 and 70. The median value of the sum-score in the sample was 61.5, Cronbach’s α was 0.83, intraclass-correlation was 0.52, the correlation with the overall rating of hand-over quality was ρ = 0.83 (p ≤ 0.001).

Conclusions

The ED-HFH showed its feasibility, reliability and validity as a measure of quality of information transfer and human factors in handovers between ambulance services  and the emergency department. It promises to be a useful tool for quality assurance and staff training.

Telephone Triage Toolkit for Children's cancer services: A quality initiative

PURPOSE

Service development to improve patient safety and experience, and improve staff safety and confidence when managing telephone calls from parents or carers of children with cancer in the UK.

METHOD

A multi-layered mixed methods approach broadly based on sequential PDSA (plan, do, study, act) cycles, to a series of quality initiative projects spanning 14 years. Various project styles and methods are described.

RESULTS

A Telephone Triage Toolkit for children's cancer services was piloted, reviewed and rolled out across the UK. Similarities were identified between adult and paediatric cancer services when identifying the case for need, enabling partnership working. A scheduled review completed in 2020 included new developments in cancer treatment, building on user experience, local audits and national feedback, leading to a 2nd edition being implemented.

CONCLUSIONS

Ground up, quality initiatives and collaborative working across organisations can be complex but draws on a wider pool of expertise and can lead to improved parent and staff experience of services. This initiative has improved practice and has application outside the UK.

Understanding the Effect of Electronic Prehospital Medical Records in Ambulances: A Qualitative Observational Study in a Prehospital Setting

Little is known of ambulance professionals’ work practices regarding the use of medical records, their communication with patients, before and during hand over to Emergency Departments (ED). An electronic Prehospital Medical Record (ePMR) has been implemented in all Danish ambulances since 2015. Our aim was to investigate the use of ePMR and whether it affected the ambulance professionals’ clinical practice. We performed a qualitative study with observations of ePMR use in ambulance runs in the North Denmark Region. Furthermore, informal interviews with ambulance professionals was performed. Analysis was accomplished with inspiration from grounded theory. Our main findings were: (1) the ePMR is an essential work tool which aided ambulance professionals with overview of data collection and facilitated a checklist for ED hand overs, (2) mobility and flexibility of the ePMR facilitated conversations and relations with the patients, and (3) in acute severe situations, the ePMR could not stand alone in hand over or communication with the ED. The ePMR affected the ambulance professionals’ work practice in various ways and utilization of ePMR while simultaneously treating patients in ambulances does not obstruct the relation with the patient. To this end, the ePMR appears feasible in collaboration across the prehospital setting.

Communication between pre-hospital and intra-hospital emergency medical services: literature review

OBJECTIVES

to analyze, according to the scientific literature, communication strategies in the transfer of cases between pre-hospital and in-hospital services and their contributions to patient safety.

METHODS

this is a literature review study, that is, one that aims to gather and synthesize research results on the subject in a systematic and orderly manner.

RESULTS

ten articles were published, published between 2010 and 2018, and two points of discussion emerged: use of mnemonics; and barriers to transferring a case.

CONCLUSIONS

studies point to the need to standardize the case transfer process, as well as integrative training of professionals, regular assessment of the teams involved in emergency medical services and the need for research on the subject.

Impact of a Standardized EMS Handoff Tool on Inpatient Medical Record Documentation at a Level I Trauma Center

BACKGROUND

The emergency department (ED) poses challenges to effective handoff from emergency medical services (EMS) personnel to ED staff. Despite the importance of a complete and accurate patient handoff report between EMS and trauma staff, communication is often interrupted, incomplete, or otherwise ineffective. The Mechanism of injury/Medical Complaint, Injuries or Inspections head to toe, vital Signs, and Treatments (MIST) report initiative was implemented to standardize the handoff process. The objective of this study was to evaluate whether documentation of prehospital care in the inpatient medical record improved after MIST implementation.

METHODS

Research staff abstracted data from the EMS and inpatient medical records of trauma patients transported by EMS and treated at a Level I trauma center from January 2015 through June 2017. Data included patient demographics, mechanism and location of injury, vital signs, treatments, and period of data collection (pre-MIST and post-MIST). We summarized the MIST elements in EMS and inpatient medical records and assessed the presence or absence of data elements in the inpatient record from the EMS record and the agreement between the two sets of records over time to determine if implementation of MIST improved documentation.

RESULTS

We analyzed data from 533 trauma patients transported by EMS and treated in a Level I trauma center (pre-MIST: n = 281; post-MIST: n = 252). For mechanism of injury, agreement between the two records was ≥96% before and after MIST implementation. Cardiac arrest and location of injury were under-reported in the inpatient record before MIST; post-MIST, there were no significant discrepancies, indicating an improvement in reporting. Reporting of prehospital hypotension improved from 76.5% pre-MIST to 83.3% post-MIST. After MIST implementation, agreement between the EMS and inpatient records increased for the reporting of fluid administration (45.6% to 62.7%) and decreased for reporting of pain medications (72.2% to 61.9%).

CONCLUSIONS

The use of the standardized MIST tool for EMS to hospital patient handoff was associated with a mixed value on inpatient documentation of prehospital events. After MIST implementation, agreement was higher for mechanism and location of injury and lower for vital signs and treatments. Further research can advance the prehospital to treatment facility handoff process.

Nurse-to-nurse communication about multidisciplinary care delivered in the emergency department: An observation study of nurse-to-nurse handover to transfer patient care to general medical wards

BACKGROUND

Little is known about how Australian national safety standards for communicating multidisciplinary care are operationalised during high-risk care transitions. We examined transfer of care for complex patients from the emergency department (ED) to medical wards to explore nurse-to-nurse communication about multidisciplinary care provided in the ED.

METHODS

Using naturalistic, mixed-methods design, observation, audit and interview data were collected from a convenience sample of 38 nurses during transfer of care for 19 complex patients from the ED to medical wards at a tertiary hospital. A focus group with 19 clinicians from multiple disciplines explored explanations for findings and recommendations. Quantitative data were analysed using frequencies and descriptive statistics; the Connect, Observe, Listen, Delegate (COLD) framework informed qualitative content analysis.

RESULTS

Nurses seldom communicated multidisciplinary care at patient transfer. Most handovers included Connect and Observe (63-95%) and Listen (90%); Delegate (42%) behaviours were infrequent. Behaviours consistent with good practice recommendations (90%) and known to increase communication risk (53%) were observed. Tensions between policies and clinical processes, and information quality negatively impacted transfers.

CONCLUSIONS

This study revealed gaps in nurse-to-nurse communication about patients' multidisciplinary care. Complex factors negatively impact nurses' handover communication necessitating workarounds, and highlighting nurses' role as patient safety advocates.

Human factors challenges for the safe use of artificial intelligence in patient care

The use of artificial intelligence (AI) in patient care can offer significant benefits. However, there is a lack of independent evaluation considering AI in use. The paper argues that consideration should be given to how AI will be incorporated into clinical processes and services. Human factors challenges that are likely to arise at this level include cognitive aspects (automation bias and human performance), handover and communication between clinicians and AI systems, situation awareness and the impact on the interaction with patients. Human factors research should accompany the development of AI from the outset.

Is patient flow more efficient in Urgent Care Collaborations?

OBJECTIVE

Emergency Departments and out-of-hours General Practitioner services collaborate increasingly in Urgent Care Collaborations (UCCs) by sharing one combined entrance and joint triage. The aim of this study is to examine the difference between UCCs and providers who operate separately with respect to the efficiency of patient flow.

METHODS

This study had a cross-sectional observational design comparing three regions with UCC with three regions with usual care. Outcome measures were efficiency of patient flow, defined as a reducing length of stay (LOS), waiting time (WT) and the mean number of handovers. Data were obtained from electronic medical records.

RESULTS

LOS (median 34:00 vs. 38:52 min) and WT (median 14:00 vs. 18:43 min) were statistically significantly longer in UCCs compared with usual care. This difference is mainly explained by the prolonged LOS and WT for consulting a General Practitioner. The mean number of interunit handovers was larger in UCCs.

CONCLUSION

The results indicate that, on average, UCCs do not enhance the efficiency of patient flow. The median LOS and WT are longer in UCCs and more handovers occur in UCCs compared with usual care.

Implementing standardized, inter-unit communication in an international setting: handoff of patients from emergency medicine to internal medicine

Standardized handoffs may reduce communication errors, but research on handoff in community and international settings is lacking. Our study at a community hospital in the United Arab Emirates characterizes existing handoff practices for admitted patients from emergency medicine (EM) to internal medicine (IM), develops a standardized handoff tool, and assesses its impact on communication and physician perceptions. EM physicians completed a survey regarding handoff practices and expectations. Trained observers utilized a checklist based on the Systems Engineering Initiative for Patient Safety model to observe 40 handoffs. EM and IM physicians collaboratively developed a written tool encouraging bedside handoff of admitted patients. After the intervention, surveys of EM physicians and 40 observations were subsequently repeated. 77.5% of initial observed handoffs occurred face-to-face, with 42.5% at bedside, and in four different languages. Most survey respondents considered face-to-face handoff ideal. Respondents noted 9-13 patients suffering harm due to handoff in the prior month. After handoff tool implementation, 97.5% of observed handoffs occurred face-to-face (versus 77.5%, p = 0.014), with 82.5% at bedside (versus 42.5%, p < 0.001), and all in English. Handoff was streamlined from 7 possible pathways to 3. Most post-intervention survey respondents reported improved workflow (77.8%) and safety (83.3%); none reported patient harm. Respondents and observers noted reduced inefficiency (p < 0.05). Our standardized tool increased face-to-face and bedside handoff, positively impacted workflow, and increased perceptions of safety by EM physicians in an international, non-academic setting. Our three-step approach can be applied towards developing standardized, context-specific inter-specialty handoff in a variety of settings.

Prevalence and predictors of hospital prealerting in acute stroke: a mixed methods study

Background

Thrombolysis can significantly reduce the burden of stroke but the time window for safe and effective treatment is short. In patients travelling to hospital via ambulance, the sending of a ‘prealert’ message can significantly improve the timeliness of treatment.

Objective

Examine the prevalence of hospital prealerting, the extent to which prealert protocols are followed and what factors influence emergency medical services (EMS) staff's decision to send a prealert.

Methods

Cohort study of patients admitted to two acute stroke units in West Midlands (UK) hospitals using linked data from hospital and EMS records. A logistic regression model examined the association between prealert eligibility and whether a prealert message was sent. In semistructured interviews, EMS staff were asked about their experiences of patients with suspected stroke.

Results

Of the 539 patients eligible for this study, 271 (51%) were recruited. Of these, only 79 (29%) were eligible for prealerting according to criteria set out in local protocols but 143 (53%) were prealerted. Increasing number of Face, Arm, Speech Test symptoms (1 symptom, OR 6.14, 95% CI 2.06 to 18.30, p=0.001; 2 symptoms, OR 31.36, 95% CI 9.91 to 99.24, p<0.001; 3 symptoms, OR 75.84, 95% CI 24.68 to 233.03, p<0.001) and EMS contact within 5 h of symptom onset (OR 2.99, 95% CI 1.37 to 6.50 p=0.006) were key predictors of prealerting but eligibility for prealert as a whole was not (OR 1.92, 95% CI 0.85 to 4.34 p=0.12). In qualitative interviews, EMS staff displayed varying understanding of prealert protocols and described frustration when their interpretation of the prealert criteria was not shared by ED staff.

Conclusions

Up to half of the patients presenting with suspected stroke in this study were prealerted by EMS staff, regardless of eligibility, resulting in disagreements with ED staff during handover. Aligning the expectations of EMS and ED staff, perhaps through simplified prealert protocols, could be considered to facilitate more appropriate use of hospital prealerting in acute stroke.

Patient safety in ambulance services: a scoping review

Background

The role of ambulance services has changed dramatically over the last few decades with the introduction of paramedics able to provide life-saving interventions, thanks to sophisticated equipment and treatments available. The number of 999 calls continues to increase, with adverse events theoretically possible with each one. Most patient safety research is based on hospital data, but little is known concerning patient safety when using ambulance services, when things can be very different. There is an urgent need to characterise the evidence base for patient safety in NHS ambulance services.

Objective

To identify and map available evidence relating to patient safety when using ambulance services.

Design

Mixed-methods design including systematic review and review of ambulance service documentation, with areas for future research prioritised using a Delphi process.

Setting and participants

Ambulance services, their staff and service users in UK.

Data sources

A wide range of data sources were explored. Multiple databases, reference lists from key papers and citations, Google and the NHS Confederation website were searched, and experts contacted to ensure that new data were included in the review. The databases MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Science Direct, Emerald, Education Resources Information Center (ERIC), Applied Social Sciences Index and Abstracts, Social Services Abstracts, Sociological Abstracts, International Bibliography of the Social Sciences (IBSS), PsycINFO, PsycARTICLES, Health Management Information Consortium (HMIC), NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED),Health Technology Assessment, the FADE library, Current Awareness Service for Health (CASH), OpenDOAR (Directory of Open Access Repositories) and Open System for Information on Grey Literature in Europe (OpenSIGLE) and Zetoc (The British Library's Electronic Table of Contents) were searched from 1 January 1980 to 12 October 2011. Publicly available documents and issues identified by National Patient Safety Agency (NPSA), NHS Litigation Authority (NHSLA) and coroners’ reports were considered. Opinions and perceptions of senior managers, ambulance staff and service users were solicited.

Review methods

Data were extracted from annual reports using two-stage thematic analysis, data from quality accounts were collated with safety priorities tabulated and considered using thematic analysis, NPSA incident report data were collated and displayed comparatively using descriptive statistics, claims reported to NHSLA were analysed to identify number and cost of claims from mistakes and/or poor service, and summaries of coroners’ reports were assessed using thematic analysis to identify underlying safety issues. The depth of analysis is limited by the remit of a scoping exercise and availability of data.

Results

We identified studies exploring different aspects of safety, which were of variable quality and with little evidence to support activities currently undertaken by ambulance services. Adequately powered studies are required to address issues of patient safety in this service, and it appeared that national priorities were what determined safety activities, rather than patient need. There was inconsistency of information on attitudes and approaches to patient safety, exacerbated by a lack of common terminology.

Conclusion

Patient safety needs to become a more prominent consideration for ambulance services, rather than operational pressures, including targets and driving the service. Development of new models of working must include adequate training and monitoring of clinical risks. Providers and commissioners need a full understanding of the safety implications of introducing new models of care, particularly to a mobile workforce often isolated from colleagues, which requires a body of supportive evidence and an inherent critical evaluation culture. It is difficult to extrapolate findings of clinical studies undertaken in secondary care to ambulance service practice and current national guidelines often rely on consensus opinion regarding applicability to the pre-hospital environment. Areas requiring further work include the safety surrounding discharging patients, patient accidents, equipment and treatment, delays in transfer/admission to hospital, and treatment and diagnosis, with a clear need for increased reliability and training for improving handover to hospital.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Clinical handovers between prehospital and hospital staff: literature review

BACKGROUND

Clinical handover plays a vital role in patient care and has been investigated in hospital settings, but less attention has been paid to the interface between prehospital and hospital settings. This paper reviews the published research on these handovers.

METHODS

A computerised literature search was conducted for papers published between 2000 and 2013 using combinations of terms: 'handover', 'handoff', 'prehospital', 'ambulance', 'paramedic' and 'emergency' and citation searching. Papers were assessed and included if determined to be at least moderate quality with a primary focus on prehospital to hospital handover.

FINDINGS

401 studies were identified, of which 21 met our inclusion criteria. These revealed concerns about communication and information transfer, and themes concerning context, environment and interprofessional relationships. It is clear that handover exchanges are complicated by chaotic and noisy environments, lack of time and resources. Poor communication is linked to behaviours such as not listening, mistrust and misunderstandings between staff. While standardisation is offered as a solution, notably in terms of the use of mnemonics (alphabetical memory aids), evidence for benefit appears inconclusive.

CONCLUSIONS

This review raises concerns about handovers at the interface between prehospital and hospital settings. The quality of existing research in this area is relatively poor and further high-quality research is required to understand this important part of emergency care. We need to understand the complexity of handover better to grasp the challenges of context and interprofessional relationships before we reach for tools and techniques to standardise part of the handover process.