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Effective Communication Between Providers & Physicians Improves Patient Hand-offs

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The “hand-off”—or transfer of patient care from prehospital providers to emergency department (ED) physicians, trauma surgeons or critical care physicians—represents one of the most important elements of successful care for patients with serious injuries or illnesses. Hand-offs involve the transfer of rights, duties and obligations from one person or team to another.(1)

Developing the means to transfer information with effective communication skills can’t be underemphasized in EMS. To be proficient in today’s fast-paced EMS culture, one must devote considerable time and effort to acquiring and developing these skills. This article highlights pertinent aspects of prehospital and medical literature that provide examples of how EMS hand-offs can be effectively and efficiently accomplished.

Understanding Doctors & Nurses
In critical care settings, communication loads can be extremely high, complex and cognitively taxing. Interruptions and multiple concurrent tasks may lead to clinical errors due to disrupted memory processes.(2) Indeed, studies have shown that when patient information is conveyed only via verbal means, few facts are retained. (3,4) Thus, miscommunication is common and can disrupt memory and lead to mistakes; hence, it’s not surprising that ED staff members remember less than half of the information EMS crews give them at verbal hand-offs.(5)

Although much of the present literature has been devoted to physician-to-patient and physician-to-physician communication, the principles gained from this research are applicable in EMS. Improving the communication between healthcare staff by reducing the levels of interruptions and minimizing the volume of irrelevant or unnecessary information exchange could have important implications for patient safety.(6)

Importance of Hand-offs
Communication deficiencies exist at all levels, and miscommunication has the potential to result in errors that could compromise patient safety. One study done in Australian EDs showed that nearly one in 10 patients may be adversely affected as the result of poor communication.(7) Likewise, timely and effective communication between EMS and the receiving hospital has the potential to save lives and improve patient eligibility for time-sensitive therapies. For instance, in a study of EMS providers who provided hospital staff with advanced notification of incoming stroke patients, the number of patients eligible for thrombolytic therapy significantly improved.(8)

Effective communication and teamwork are essential for the provision of high-quality and safe patient care. Unfortunately, communication failures continue to be a common cause of inadvertent patient harm, and methods to improve communication remain an important focus for further education and research in EMS.(9)

Tips for Improvement
The complexity of medical care, coupled with the inherent limitations of human performance, make it critically important for EMS professionals to standardize communication techniques. In a survey of emergency medicine nurses, hand-offs conducted in a structured fashion were pivotal in ensuring that patients received the correct care and that that care was provided at the appropriate level.(10)

A structured approach is crucial, and communication failures often result from an unrecognizable or disorganized approach.(11) It’s important to remember that prearrival communications should be kept as concise as possible because the time spent giving a prearrival report is frequently duplicated in the ED.

Moreover, although jurisdictional protocols vary from region to region, radio reports, especially for low-priority patients, may not be an efficient or productive use of providers’ or nurses’ time.12 For prehospital reporting, the mnemonic “E-STAT,” which stands for “subjective findings,” “triage/time,” “allergies/assessment,” and “treatment” can help providers remember the crucial components of a hand-off in the absence of an established receiving hospital form.

Pnemonic for Hand-off Report
E: Events prior/why EMS was called
“We were called to the scene of this 72-year old woman who presented with the chief complaint of left-sided weakness and slurred speech.”
S: Subjective Findings
“Her husband noticed that her speech was slurred and that she appeared to have facial weakness. Over the next 30 minutes, she subsequently developed left-sided weakness and was unable to stand on her own.”
T: Triage/time
“We transported her as a priority 1 patient under the suspected stroke protocol;”
“Her husband noticed that the symptoms started at approximately 8:30 this morning.”
A: Allergies/assessment
“She has a rash with penicillin and amoxicillin;”
“On exam, she was found to have left sided-weakness, 3/5 strength in the left upper and lower extremities and slurred speech;”
“She has a past medical history significant for coronary artery disease, stable angina, osteoarthritis and type I diabetes.”
T: Treatment
“En route, she was provided with oxygen by face mask at 10 Liters per minute. Her symptoms didn’t improve en route.”

Conclusion
The aim of all EMS hand-offs is to ensure a smooth and efficient transfer from the prehospital scene to definitive medical care. Placing an emphasis on training with structured communication tools can decrease the risk of communication failures. Understanding the importance of effective communication and what it contributes to the continuity of care and enhanced patient safety is indispensible for the EMS provider.

References
1. Solet D, Norvell J, Rutan G, et al. Lost in translation: Challenges and opportunities in physician-to-physician communication during patient hand-offs. Acad Med. 2005;80(12):1094–1099.
2. Coiera E, Javasuriya R, Hardy J, et al. Communication loads on clinical staff in the emergency department. Med J Aust. 2002;176(9):415–518.
3. Bhabra G, Mackeith S, Monteiro P, et al. An experimental comparison of handover methods. Ann R Coll Surg Engl. 2007;89(3):298–300.
4. Pothier D, Monteiro P, Mooktiar M, et al. Pilot study to show the loss of important data in nursing handover. Br J Nurs. 2005;14(20):1090–1093.
5. Talbot R, Bleetman A. Retention of information by emergency department staff at ambulance handover: Do standardised approaches work? Emerg Med J. 2007;24(8):539–542.
6. Woloshynowych M, Davis R, Brown R, et al. Communication patterns in a UK emergency department. Ann Emerg Med. 2007;50(4):407–413.
7. Ye K, Taylor D, Knott J, et al. Handover in the emergency department: Deficiencies and adverse effects. Emerg Med Australia. 2007;19(5):433–441.
8. Abdullah A, Smith E, Biddinger P, et al. Advance hospital notification in acute stroke is associated with shorter door-to-computed tomography time and increased likelihood of administration of tissue-plasminogen activator. Prehosp Emerg Care. 2008;12(4):426–431.
9. Leonard M, Graham S & Bonacum D. The human factor: The critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(Suppl 1):i85–i90.
10. Bruce K, Suserud B. The handover process and triage of ambulance-borne patients: The experiences of emergency nurses. Nurse Crit Care. 2005;10(4):201–209.
11. Penner M, Cone D & MacMillan D. A time-motion study of ambulance-to-emergency department radio communications. Prehosp Emerg Care. 2003;7(2):204–208.
12. Theorem T, Morrison W. A survey of the perceived quality of patient handover by ambulance staff in the resuscitation room. Emerg Med J. 2001;18(4):293–296.
 



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