One of the recognized challenges in prehospital care (EMS) is the safe and effective transfer of care between prehospital and hospital emergency department (ED) providers. A patient care hand-off involves persons or teams both providing information and transferring the responsibility for care to another person or team (Blouin, 2011). Patient care hand-offs in this environment are often lacking standardization yielding significant safety risks.
Hospital ED and prehospital provider members of the Central Ohio Trauma System (COTS), a regional trauma organization (RTO), convened to develop a regional standardized hand-off education plan that was implemented in two phases. Phase I consisted of the development of a hand-off data collection tool and performance of a pre-assessment to define problem, then generation of an intervention. Phase II consisted of a post-assessment to evaluate the impact of the implementation.
The education plan development and implementation occurred over a two-year period. In Phase 1, we identified significant loss of data with only 69% of demographics and 20% of vital signs captured in hand-offs. Only 21% of hand-offs lasted less than 60 seconds. Following the implementation of the hand-off standardization and education plan, the Phase II assessment revealed a large overall system improvement with 92% of demographics captured, 80% of vital signs, and 46% of hand-offs being less than 60 seconds.
Specific to Phase II data collection, it was shown that 77% of hand-offs included all aspects of the MIST (a standardized hand-off tool that includes mechanism, interventions, symptoms and treatment information often used by emergency medical technicians). In addition, 71% of EMS (sender) felt they were acknowledged by the ED staff (receiver). There was significant improvement in data collection and hand-off communication with a standardized approach.
Standardized educational plans may assist other regional organizations in improving hand-offs as a patient safety initiative. Further, the use of this model may lead to the identification of communication gaps in the user’s system of care. The collaborative structure at COTS provided a framework for all healthcare providers and systems to reach a common goal. Standardizing the hand-off process helps to better ensure the sender and the receiver are working in unison, thus creating a safer environment and improving outcomes.
One of the recognized challenges in prehospital care is the safe and effective transfer of care between prehospital and hospital providers. This has risen to the level of a significant patient safety risk since there is large loss of data between the two teams who should be functioning in unison (Chapman et al., 2016; Reay et al., 2019; Sumner et al., 2019; Panchal et al., 2015). Previously, The Joint Commission (2012) identified communication as the root cause of 80% of hospital-based sentinel events and that 50% of these events occurred during patient hand-offs producing a concern for patient safety.
The Institute of Medicine (1999; 2009) estimated deaths related to medical errors at 44,000 and as high as 98,000 per year in the U.S. Makary and Daniels (2016) report that medical errors may result in 251,000 deaths per year in the U.S.; 9.5% of all U.S. deaths annually. A large part of these medical errors involves communication breakdown when patient care is handed off from one healthcare provider to another.
The Joint Commission (TJC) (2017) defines a hand-off as a “transfer and acceptance of patient care responsibility achieved through effective communication.” A hand-off of care involves persons or teams who both provide information and transfer the responsibility for care to another person or team (Blouin, 2011). The purpose of the hand-off should be to ensure continuous and safe patient care. The roles of a quality hand-off include:
Sender – sends or transmits the patient data and releases patient care to the receiver;
Receiver – receives the patient data and accepts care of the patient (TJC, 2017).
Substandard hand-offs can cause serious or fatal consequences including, but not limited to, delay in treatment, inappropriate treatment, care omission, increased length of hospital stay, readmissions, increased costs, inefficient care from rework and minor and/or major patient harm (TJC, 2017).
Recognizing the urgent need to address this issue, the American College of Emergency Physicians (ACEP), Emergency Nurses Association (ENA), National Association of EMS Physicians (NAEMSP), National Association of Emergency Medical Technicians (NAEMT), and National Association of State EMS Officials (NASEMSO) jointly published a position statement with key principles to improve patient hand-off safety (NAEMPS, 2014).Although these movements have identified the larger challenge, it is incumbent on local champions to change the paradigm and improve the hand-off process (TJC, 2017).
In Central Ohio, emergency medical service (EMS) and hospital members of the Central Ohio Trauma System (COTS) collaborated to improve patient safety by standardizing regional EMS to emergency department (ED) patient hand-offs. The Central Ohio Trauma System, a voluntary 501c3, is a group of physicians, healthcare professionals and other experts working together to improve outcomes related to trauma, emergency services, and disaster preparedness.
The Central Ohio Trauma System provides emergency preparedness coordination to 37 of Ohio’s 88 counties. It also functions as a regional trauma organization (RTO) for those same 37 counties and manages a voluntary trauma data registry. All hospitals participating in data submission to the RTO are invited to collaborate in emergency and trauma initiatives. The Emergency Services division of COTS serves as a liaison between first responders and hospital EDs.
By utilizing a collaborative approach and shared values, COTS strives to solve difficult healthcare delivery challenges through evidence-based research, data collection, and best practice strategies. All COTS partners share in the mission of improving patient outcomes and in doing so, they provide value to the community. The development of a standardized patient safety hand-off process met the mission of COTS.
Hospital member champions included the EDs of the Ohio State University Wexner Medical Center, the Ohio State University East Hospital, and Diley Ridge Medical Center and the EDs and free standing EDs of Nationwide Children’s Hospital, Mount Carmel Health System, and OhioHealth. Emergency medical service agency champions included COTS participating agencies who transported their patients to the participating hospitals.
In the region, multiple barriers were identified concerning patient care transfers from prehospital providers to the ED staff. In the prehospital setting, there were numerous forms of EMS patient hand-offs being performed which were all appropriate, but no single identified best practice model. Furthermore, the large number of EDs in central Ohio made the hand-off process challenging for prehospital providers.
Each facility had different processes for transferring information from the EMS to the ED staff. For example, ED call taker report sheets and the data points included for the radio calls differed between facilities. Once EMS arrived at the EDs, the process for assigning patients to rooms and the person greeting EMS differed by facility. To assess the scope of the challenge, the COTS Emergency Services Advisory Board assigned the project to the COTS Emergency Services Workgroup. This workgroup consisted of participating hospital ED nurse leaders and EMS coordinators and prehospital EMS coordinators. After a literature review, a trained observer program was developed to witness EMS hand-offs in the EDs for collection of objective data on the hand-off process and to identify communication gaps and areas of information loss. The trained observers were members of the workgroup or their assigned designee who were educated to collect data using a unified hand-off data collection tool. (See Figure 1).
This was done through an educational “hand-off” presentation describing the data collection tool and collection process. Each observer was required to review the educational presentation prior to beginning data collection. Over a two-week hand-off evaluation period during September 2016, the trained observers utilized the Hand-Off Data Collection Toolv1 to evaluate five cases each from the following categories: trauma, medical, stroke and STEMI.
The Emergency Service Workgroup identified 21 data elements and developed nine questions to evaluate the hand-off process. Ninety observations were made, and they were submitted to the COTS performance improvement (PI) coordinator for de-identification, summary and analysis. The observations in Phases I included 46% of medical cases (N=41), 26% of trauma cases (N=23), 18% of stroke cases (N=16), and 10% of STEMI cases (N=10). Phase I findings included:
- Only 21% of the hand-offs were recorded as less than 60 seconds with the longest hand-off lasting 15 minutes
- Patient demographics from hand-offs were captured at a rate of 69%
- All the vital signs were reported in only 20% of the observations on average over all four categories
- Observed patients were determined to be stable 56% of the time followed by 23% urgent, 19% emergency, and 2% not specified
- 100% of the stroke hand-off reports lasted longer than 60 seconds
- It was noted that hand-off reports were interrupted in five cases
Weakness of the data collection included the fact that sites evaluated did not always submit the total of 20 charts (five per category) nor did they submit the same number in each category, yielding inconsistency in the reported numbers. In addition, there were times when fields were left blank, making it unclear if they meant “0” or they forgot to fill it out. Therefore, the COTS PI coordinator only counted the numbers that were present and did not make any assumptions regarding the data.
After review of the data and recognizing an opportunity for improvement, the COTS Emergency Services Workgroup was charged with developing the best intervention for its member hospitals and EMS. Developing a recommendation that coordinates four health systems, including Level I and Level II trauma centers, acute care hospitals, and free standing EDs and approximately 100 EMS agencies was challenging.
The key to success would be engagement and coordination with all provider networks for this patient safety initiative to be effective. After a detailed review of the literature, the COTS workgroup determined the MIST (Mechanism, Intervention, Symptoms, and Treatment) hand-off developed by The Southwest Texas Regional Advisory Council (STRAC) as a best practice solution for COTS partners (Friese, 2016). (See Figure 2:)
The STRAC process was chosen as the best fit for COTS partners due to its overall compliance with current Joint Commission (2017) hand-off communication guidelines. In adapting the tool, hand-off process, and education for Central Ohio, the following education plan was developed to include the MIST Tool (Central Ohio Trauma System, 2018).
- A coordinated guideline for regional EMS agencies and ED leadership to provide education to the target health professionals.
- An EMS MIST hand-off tool for distribution to and display in the EDs and EMS agencies. (See Figure 2 above).
- A training video for ED nursing staff and EMS providers endorsed by the Central Ohio Trauma System, Central Ohio Hospital Council, and the Central Ohio Fire Chiefs’ Association. View video here.
- A plan to provide education to EMS and ED nursing staff of participating hospitals.
With a goal to achieve consistency in hand-off communication and to decrease or eliminate missed information from EMS to hospitals, planning had to be precise and organized. After securing commitments from hospital leadership and EMS chiefs, education roll-out began during National EMS Week May 2017.
An informational letter and links to the web-based MIST hand-off education plan was provided to ED leaders, EMS chiefs, and local emergency medical technician training schools to incorporate into their program curriculum. The MIST hand-off education plan was also shared with the Ohio Hospital Association, the Ohio Department of Public Safety, Division of Emergency Medical Services, and local critical care transport and private ambulance services as best practice initiatives.
The workgroup developed a timeline for implementation of the EMS Time out Project to track implementation and benchmarks of progress. (See Figure 3 Hand-off Project Timeline).
The education roll-out utilized nurse leaders and EMS Coordinators from all participating health systems to provide education and training to nursing staff while EMS Coordinators from the participating EMS agencies worked to educate and train their providers. With well over one thousand providers to educate and train, this was no small task.
The plan leveraged internal structures in both the health systems and EMS agencies to educate providers on the MIST hand-off process. Following re-education of the front-line providers, we received anecdotal reports from hospital and prehospital participants of some improvement in the hand-off process, but barriers still existed.
As part of the continuous quality review of this project, the workgroup identified a need to supplement the hand-off communication training with an additional education session. In November 2017, a detailed video was developed by COTS and led by a local ED and EMS medical director and the president of the COTS Emergency Services Advisory Board. The goal of this educational video was to explain the purpose for the process change (the why), provide examples of an effective hand-off, and review case studies demonstrating opportunities for improvement.
Continuing education was provided for the live training and 100% of attendees completing an evaluation reported the learning opportunity met their learning needs and that they would be able to apply the new knowledge to their practice. This supplemental video was posted on the COTS website for future use and included in the hand-off process education for new partners.
The workgroup reconvened to review the Data Collection Tool and agreed by consensus to add three optional questions for the second phase of data collection based on review of the Phase I data. (See Figure 4.). The following three yes/no questions were added as optional to determine the interaction between the sender and receiver of information.
- Did ED staff interrupt during the timeout?
- Did EMS provide all MIST information?
- EMS timeout was acknowledged.
In April/May 2018, trained observers were re-deployed to re-educate the staff on the hand-off process.
Data collection for the second phase of trained observer reviews occurred during the months of June, July, and August 2018, exactly one month after the re-education. Results from the second survey, compared with the first, were significant. Second phase observations obtained were N=439 compared to the initial observations of N = 90. he second phase of observations were also submitted to the COTS PI coordinator for de-identification, summary, and analysis. The observations in Phase II included 72% of medical cases (N=316), 19% of trauma cases (N=84), 3% of stroke cases (N=12), and 2% of STEMI cases (N=11). Phase I findings included:
- 46% of the hand-offs were recorded at less than 60 seconds with the longest hand-off being six minutes. We originally discuss 30 seconds, based upon the review by Friese (2016), but the general consensus of the group was to allow up to 60 seconds as the threshold
- Demographics, (Name, date of birth, past medical history, allergies and current medications) were completed in 92% of the observations.
- All the vital signs were reported in 80% of the observations over all four categories
- 82% of the EMS (sender) hand-off reports were not interrupted by ED staff (receiver)
- 77% of EMS (sender) hand-off reports included all the MIST information
- 71% of the time EMS (sender) timeout was acknowledged by the ED staff (receiver)
- 75% of the patient observations were determined to be stable, 18% urgent, 5% emergent, and 2% were not specified
Comparison of Phase I versus Phase II data collection:
- In Phase II, 46% of the hand-offs were recorded at less than 60 seconds versus 21% in Phase I
- All vital signs were reported in 80% of Phase II compared to only 20% of Phase I
- Demographics were captured at rate of 92% in Phase II versus 69% in Phase I
- In Phase I, the longest hand-off was 15 minutes and in Phase II, it was 6 minutes.
When we provided the education, discussed the process, and implemented the new tools and techniques initially, we did not attain the buy in that we expected—EMS providers and ED staff were hesitant to adopt this new process. As we drilled down to identify the cause of this hesitancy, we came to understand we had not explained effectively why this change was necessary.
We reconvened the workgroup to discuss how we could educate the frontline provider on why this initiative was needed. Subsequently, a detailed video was developed, and it included the purpose for the process change, examples of an effective hand-off, and case studies demonstrating opportunities for improvement. The video was led by a physician EMS medical director in collaboration with COTS. The video was impactful and distributed to the region as follow up to the initial training.
A quality patient care hand-off is a critical part of patient care. Multiple national organizations stress the importance of a safe and effective transfer of care from one group of providers (sender) to the next (receiver) and the EMS community is at the beginning of this significant process. The collaborative structure at COTS provided a framework for all healthcare providers and systems to reach a common goal. Moving forward we have communicated to all of the EMS agencies to add the video and hand-off process into their on-boarding of new EMS providers.
In addition, this information was shared on our COTS website and with the local EMS training schools to education their students and provide early awareness of the significance of a well-structured EMD Hand-off process. Standardizing the hand-off process helps to better ensure the sender and the receiver are working in unison, thus creating a safer environment and improving outcomes.
Thank you to GeoffreyFinnegan, EMT, Senior Data Analytics Specialist, Cancer Program Analytics, The Ohio State University Center for EMS for assistance in data collection tool development and data analysis.
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