It is a typical day in the emergency department. An 83 yo female is brought in by EMS after family called 911 because the patient was not herself. The patient’s vital signs are reportedly within normal limits, so she is triaged to a regular room in the emergency department where handoff is given from paramedic to nurse. The physician, who is in another room, is not present for the signout. Ten minutes later, the physician walks into the room to see the patient. Her family is not present. Because paramedics had to leave rapidly for another call, the prehospital patient-care record is not in the chart and there is minimal documentation of what was communicated in the handoff. The patient, who is oriented only to self, states only, “I’m not sure why I’m here.” The physician continues with his physical exam, hoping he can find other clues as to why the patient is here.
A couple weeks ago, we asked our readers to consider this case and discuss the following questions:
What are some of the barriers you have encountered to quality patient handoffs from prehospital to in-hospital providers ?
Most importantly, what initiatives has your EMS system implemented to address this issue in patient care?
Below you will find a summary of this discussion.
Handoffs are defined as the transfer of information, professional responsibility and accountability between caregivers. Whenever they occur, handoffs are a critical component of quality patient care and have enormous influence on patient trajectory within the clinical environment. Failures of communication during transfer of patient care are major drivers of error and patient harm within the current healthcare system [1,2].
For a multitude of reasons, handoffs between prehospital and in-hospital clinicians are logistically difficult and vary in quality. A quantitative analysis of the content of 90 EMS to ED handoffs involving critically ill patients found significant deficiencies in information transfer . Only 78% (95% CI, 70.0-86.7) of handoffs included a chief concern, 47%(95% CI 31.3 – 57) included pertinent physical exam findings, and 58% (95% CI 47.7 – 67.7) provided a description of the scene. The reason for such omissions is likely multi-factorial. A qualitative study of EMS provider focus group-based discussions of handoffs identified some common themes . EMS providers expressed frustration with a disorganized process that inhibited their ability to act as patient advocates. Disorganization was predominantly due to lack of time, focus, standardization, and respect for the healthcare role of the EMS provider. When asked to comment on “barriers to quality handoffs”, our readers focused on these themes as well:
Interruptions are the norm in the chaotic environment of the emergency department. In one study, emergency physicians were interrupted 9.7 times per hour and spent 6.4 minutes out of every hour performing simultaneous tasks . Following such interruptions, emergency physicians failed to return to a significant percentage (19%) of tasks. In one study of emergency department communication, 30.1% of communication events were found to be interruptive and 10% of communication time involved two or more concurrent conversations . Interruption is the cultural and operational norm of the emergency department, including during times of information transfer. This undoubtedly leads to information loss and negatively impacts patient care. The question remains: how do we fix it?
One of the major themes that emerged from our reader’s comments was that of standardization:
Indeed, in a joint statement, NAEMSP, the American College of Emergency Physicians (ACEP), Emergency Nurses Association (ENA), National Association of Emergency Medical Technicians (NAEMT) and the National Association of State EMS Officials (NAEMSO) wrote that a “clearly defined processes for the contemporaneous face-to-face communication of key information from … EMS providers to health care providers in an emergency department are critical to improving patient safety, reducing medicolegal risk, and integrating EMS with the healthcare system.” . But is standardization of the handoff process effective in improving the quality of information transfer?
In 2007, a study was published that evaluated the effect of implementing a standardized tool on retention of information by ED staff following EMS handoffs . The study measured information recall by the ED staff during unstructured handoffs versus handoffs structured in the “DeMIST” format: Demographics, Mechanism of injury/illness, Injuries (sustained and suspected), Signs (including observation and monitoring), and Treatment given. Overall, they reported a non-significant decrease in information retained after implementation of the standardization tool (from 56.6 to 49.2%), which is disheartening until the study is evaluated more closely. First, only EMS providers were trained in the format, and this training was minimal. Second, only 18 unstructured handoffs and 10 structure handoffs were evaluated. Therefore, the take-home of this study is not that standardization is ineffective, but that simply changing the format of the handover, rather than the process of the entire system (EMS and ED) is ineffective in creating change.
On the hospital side, there is some evidence that standardization of information transfer can be effective in improving patient-centered outcomes. A very large study of the effect of implementing a standardized handoff tool for pediatrics residents (I-PASS) found a 23% decrease in the medical-error rate in 10,740 patient admissions . Importantly, the intervention was not limited to the mnemonic itself, but included extensive education, resident feedback, and a culture-change campaign.
One of our readers commented specifically on a local initiative in standardization:
The Monroe-Livingston Region in upstate New York enacted a program entitled “Effective Patient Handoffs”. This program employs a standardized MIST handoff tool for the transfer of information (see Figure). Moreover, it requires that information transfer is the singular focus of the interaction (i.e. occurs prior to and not simultaneously with movement of the patient). It is not a unilateral initiative, but elicited the collaboration of emergency departments in the area. Educational videos and posters are provided on the website. Based on the I-PASS study, such tools are essential to creating the cultural change to enable effective implementation.
But verbal communication is only part of the communication between EMS and the ED. As noted by the joint statement by NAEMSP, ACEP, ENA, NAEMT and NAEMSO, “verbal information alone may lead to inaccurate and incomplete documentation of information and inadequate availability of information to subsequent treating providers… who are not present at the verbal communication.” . Indeed, the study of the DeMIST handoff tool reinforced this concept by demonstrating that only about half of information is retained following the verbal transfer of information . Several of the comments addressed the importance of written documentation during transfer of information:
EMS documentation is part of the healthcare record, but counter to this fact, many EMRs fail to integrate prehospital information into the patient’s permanent care record. Beyond written documentation of the handoff by the direct receiver (triage note), the EMS patient care record, including prehospital testing such as glucose measurement and ECG, are often unavailable within a clinically relevant period of time. While most electronic records are designed to capture billing information, we must remain vigilant that they effectively perform what should be their primary role – efficient transfer of information for patient benefit. While we wait for technology to catch up (as it has in other parts of the world such as Holland per our reader’s comments), we must remain consistent in recognizing the value of prehospital written documentation.
The handoff between EMS and the ED is a critical moment in patient care. As clinicians working in the prehospital environment, emergency department or both, we must change both the process and culture surrounding verbal and written documentation if we are to do the best for our patients.
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Discussion summary by EMS MEd Editor, Maia Dorsett MD Phd (@maiadorsett)
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2. Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., ... & Lipsitz, S. R. (2014). Changes in medical errors after implementation of a handoff program. New England Journal of Medicine, 371(19), 1803-1812.
3. Goldberg, S. A., Porat, A., Strother, C. G., Lim, N. Q., Wijeratne, H. S., Sanchez, G., & Munjal, K. G. (2017). Quantitative analysis of the content of EMS handoff of critically ill and injured patients to the emergency department. Prehospital Emergency Care, 21(1), 14-17.
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7. American College of Emergency Physicians, Emergency Nurses Association, National Association of EMS Physicians, & National Association of State EMS Officials. (2014). Transfer of patient care between EMS providers and receiving facilities. Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 18(2), 305.
8. Talbot, R., & Bleetman, A. (2007). Retention of information by emergency department staff at ambulance handover: do standardised approaches work?. Emergency Medicine Journal, 24(8), 539-542.