Literature and study team experience indicate emergency medical services (EMS) to emergency department provider handoffs could be an opportunity for improvement in emergency medical care. To date, no study has been published to specifically determine the perceived quality of handoffs between EMS and emergency department providers in the state of Minnesota. This exploratory project could help provide insight toward improving handoffs and guide future research and quality improvement projects.
We conducted our study using two surveys, one targeted to EMS and one targeted to emergency department (ED) providers. Our survey for ED providers was sent to all trauma medical directors in Minnesota and posted in the newsletter of the Minnesota chapter of the American Academy of Family Physicians. Providers were eligible if they covered at least one ED shift in the preceding month. Our survey for EMS personnel was sent to all of the Minnesota and adjacent area regional directors of EMS services. Using SAS v9.4, both quantitative and qualitative survey data were compiled and analyzed.
Of the 52 completed survey respondents 30 were ED providers and 22 were EMS. All of the ED provider respondents were MD/DOs, and for the EMS providers most were EMT and a few were paramedics. All of the EMS respondents were from southwestern Minnesota. One third of the ED providers were from an urban county and two thirds were from a rural county. The average number of years practicing for EMS and ED providers was 15.8 (9.9) and 20.3 (9.7), respectively. The number of handoffs received in the past month for EMS and ED providers was 16.6 (18.7) and 23.1 (20.2), respectively.
Ninety-seven % of ED providers rated the quality of their most recent handoff from EMS as either meeting or exceeding expectations. Half of the ED providers estimated a high percentage (75-100%) of handoffs contain minimum key information. Another 40% indicated a low percentage of handoffs (0-33%) contain minimum key information. This was true in both urban and rural counties. Eighty-six % of EMS personnel rated the quality of their most recent handoff as either meeting or exceeding expectations. Sixty-four % estimated a high percentage (75-100%) of their handoffs contain minimum key information. Several suggestions were provided for improving handoffs in the qualitative data.
Both the quality of the last EMS to ED provider handoff and the percentage of these handoffs containing key information did not differ based on years of experience nor in number of handoffs participated in during the preceding month.
Numerous research studies report adverse outcomes in hospitals as a result of poor handoffs between healthcare professionals. During handoffs between EMS and emergency department providers, many opportunities arise for vital key information to be missed.1-2 In one study completed in one academic center’s emergency department treating more than 100,000 patients annually, key information from EMS was missing from many handoffs. For example, the same study reported the following: a chief complaint was included in 78% of handoffs, vital signs in 57%, pertinent physical exam findings in 47%, and overall assessment of patient status in 31%.1
- Collaboration: The Key to a Successful Patient Care Hand-off
- The Importance of Complete, High-Quality Patient Handoff Reports
All of these components of clinical information are essential to reduce errors and enhance patient care. According to the position statement from the National Association of EMS Physicians, clearly defined processes for face-to-face communication of key information from EMS providers to emergency department providers are essential to improve patient safety, reduce medical errors, and vertically integrate EMS successfully with a health-care system.3 The position statement further emphasizes that “verbal information alone may lead to inaccurate or incomplete documentation of information and inadequate availability of information to subsequent treating providers.”3
To optimize care, it is vital to communicate important information regarding the patient, not only in direct conversation yet also via written documentation and effectively transferred. It is also important that both EMS and emergency providers perceive the handoff to be of good quality. In an observational study of handoffs, there was no correlation between emergency department perceptions of the handoff from EMS and whether or not key information was missing from the handoff.2 Therefore, the quality of handoffs cannot be measured solely from what the provider believes to be a good handoff. Nonetheless, it remains important that both the EMS and the emergency medical providers view the handoff as a good quality handoff.
To limit the amount and severity of errors and to improve patient outcomes, numerous strategies have been suggested to improve handoffs between EMS and emergency department providers. One suggested strategy is to introduce structure to the handoffs,3, 5 or at least standardize a portion of the handoffs.4 Another suggestion promotes the addition of mobile web-based technology to compliment the handoffs.5 Examples of these technologies include the following: adding videos which EMS can compose and transmit; video monitoring within the ambulance; and/or expanding the capabilities and permissions for EMS personnel to take and transmit images to the receiving hospital to augment the handoffs.
Our research project was reviewed by the University of Minnesota Institutional Review Board (IRB) which determined the survey did not constitute human research. Two surveys, each 10 questions in length, were distributed using REDCap. One survey was sent to trauma medical directors including a request to forward the survey to all providers who had worked at least one shift in the prior month in an emergency department. This provider survey was also posted within the Minnesota chapter of the American Academy of Family Physicians’ quarterly newsletter.
Correspondingly, the EMS survey was sent to the regional directors of EMS in the eight regions designated on the (EMSRB) Emergency Medical Services Regulatory Board’s website. However, responses were only received from the Southwest region of Minnesota. Regional EMS directors were asked to forward the survey to all EMS workers who had worked at least one shift in the prior month. Items that were included in the survey included provider’s and EMS personnel’s level of training and number of years practicing county where they primarily work, number of patient handoffs in the past month, questions about the quality of the handoff, whether handoffs are currently a part of any QI project in the health system, telehealth use, and suggestions for improvements of handoffs. (See appendix for complete survey questions).
Data Collection and Analysis
Data were collected using REDCap and were then exported into Excel for data analysis. Data analysis was completed using SAS v.9.4 (SAS Institute Inc., Cary NC). P-values <0.05 were considered statistically significant. Descriptive statistics were calculated for all survey items (means and standard deviations and/or frequencies and proportions). Demographics were compared between the EMS providers and ED providers using two-sample t-tests and Fisher’s exact tests. Fisher’s exact tests were used when necessary due to small cell sizes.
Counties were classified as urban (large central metro) or rural (medium metro, small metro, micropolitan, or noncore) using the 2013 NCHS Urban-Rural Classification Scheme for Counties. Regions of Minnesota were classified using the eight Emergency Medical Services Regulatory Board (EMSRB) regions (Northeast, Metro, Central, Northwest, Southeast, Southwest, South Central, West Central).
Comparisons between the EMS providers and ED providers on the perceptions of the handoffs were only conducted qualitatively (rather than statistically), due to large differences between these two groups in location and organizations. Within provider type, the association between the percent of key information included in handoffs and the provider’s years of experience/number of handoffs completed in the past month were assessed using Fisher’s exact tests.
Qualitative analysis for the open-ended survey question on suggestions for improving handoffs was conducted with a modified grounded theory approach, identifying themes (or categories) of responses (e.g. communication, listening, training). Counts were generated for each of the categories as appropriate and themes were reviewed and discussed by the study team.
There were 30 ED providers and 22 EMS providers that completed surveys in REDCap in August and September 2020. One paramedic completed the ED providers survey and was excluded from the results. The final sample contained 52 survey responses.
Participant demographics (Table 1):
All of the ED providers who completed the survey are MD- or DO-physicians. For EMS providers, most were EMTs, followed by a few paramedic and RNs. All EMS providers with complete county information were from the Southwest region of Minnesota (medium-small metro, micropolitan, or noncore counties). Among ED providers, most were from the Metro and Northeast regions of Minnesota, with a few providers located in Southwest, Central, Northwest, and South central.
One-third of ED providers were from large central metro counties. Due to these major region and county-size differences between the EMS and ED providers, results were only compared between the providers from outside of the large central metro, rural, (n=21 EMS providers and n=19 ED providers). EMS providers had slightly less experience with EMS/ER medicine and lower number of handoffs in the past month than ED providers, though this difference was not statistically significant.
|Table 1. Participant demographics by provider type|
|n (%) or mean (sd)||EMS provider||ED Provider||p-value*|
|Region of the state (EMSRB regions)2||N/A|
|Northwest||0 (0.0%)||1 (3.3%)|
|Northeast||0 (0.0%)||9 (30.0%)|
|West central||0 (0.0%)||0 (0.0%)|
|Central||0 (0.0%)||3 (10.0%)|
|Metro||0 (0.0%)||11 (36.7%)|
|Southwest||21 (100%)||5 (16.7%)|
|South central||0 (0.0%)||1 (3.3%)|
|Southeast||0 (0.0%)||0 (0.0%)|
|Large central metro||0 (0.0%)||11 (36.7%)|
|Medium metro, small metro, micropolitan, or noncore||21 (100%)||19 (63.3%)|
|Years practicing EMS/ED medicine||15.8 (9.9) range 1-32||20.3 (9.7) range 3-38||.109|
|Number of handoffs in the past month||16.6 (18.7) range 2-80||23.1 (20.2) range 2-90||.246|
|Notes. 1missing for n=1 EMS provider and n=1 ED provider, 2missing for n=1 EMS provider. *P-values are from two-sample t-tests.|
ED provider perceptions of EMS to ED handoffs (Table 2):
Overall, 97% of ED providers rated the quality of their most recent handoff as either meeting or exceeding expectations. The only two ED providers that chose “exceeded expectations” were located in urban counties. Half of the ED providers estimated a high percentage (75-100%) of handoffs contain the minimum key information, while 40% of ED providers surveyed said that a low percentage (0-33%) of handoffs contain the minimum key information.
This was relatively similar between urban and rural counties. About 87% of ED providers reported there is a perceived structure to the handoffs, and about one in five ED providers mentioned that EMS to ED handoffs are a current QI focus at their organization. Lastly, mobile telehealth was reported being used only for the ED providers in rural counties (6/19, 32%). Among the six ED providers that mentioned telehealth being used, five specified EKGs are transmitted/faxed ahead of the ambulance, and one mentioned TeleEM. All six of these ED providers were at hospitals in rural counties. EKGs transmitted/faxed ahead of the ambulance may be industry standard in some regions of the United States and seen as telehealth in others.
|Table 2. ED provider perceptions of EMS to ED handoffs (overall and by county type)|
|n (%) or mean (sd)||All||Outside of central metro||Large central metro||p-value*|
|Quality of most recent handoff||.126|
|Did not meet expectations||1 (3.3%)||1 (5.3%)||0 (0.0%)|
|Met expectations||27 (90.0%)||18 (94.7%)||9 (81.8%)|
|Exceeded expectations||2 (6.7%)||0 (0.0%)||2 (18.2%)|
|Percentage of handoffs containing the minimum key information1||56.6 (39.0)||53.1 (40.3)||62.6 (37.6)||.528|
|Low (0-33%)||12 (40.0%)||9 (47.4%)||3 (27.3%)|
|Medium (34-74%)||3 (10.0%)||2 (10.5%)||1 (9.1%)|
|High (75-100%)||15 (50.0%)||8 (42.1%)||7 (63.6%)|
|EMS to ED handoffs current focus of quality improvement at organization2, n (% yes)||6 (20.7%)||4 (21.1%)||2 (20.0%)||1.000|
|Perceived structure to handoffs from EMS, n (% yes)||26 (86.7%)||16 (84.2%)||10 (90.9%)||1.000|
|Mobile telehealth used prior to EMS handoff, n (% yes)3||6 (20.0%)||6 (31.6%)||0 (0.0%)||.061|
|Notes. 1Minimum key information such as vital signs, treatment interventions, and time of symptoms in written or electronic form (not including verbal), 2Missing n=1, 3See later section for details, not all of these might actually count as mobile telehealth, *p-values are from two-sample t-tests or Fisher’s exact tests.|
EMS provider perception of EMS to ED handoffs (Table 3):
Among EMS providers, 86% rated the quality of their most recent handoff as meeting or exceeding expectations and 64% of EMS providers estimated that a high percentage (75-100%) of their handoffs contain the minimum key information. Half of the EMS providers listed handoffs as a current focus of QI at their organization and only 24% reported their organization expects handoffs to be structured. Though, these responses may only reflect the experience of EMS providers at a single or a few organizations.
About 14% of EMS providers indicated mobile telehealth is used. Among the three EMS providers that mentioned telehealth being used, the following details were given: Sanford one call, ARMOR radio system relays report/patient status/ETA, and iPads that provide video of what happens in the truck and radios as a backup. Of these responses, two included using a system to give prearrival report, which is generally considered standard of practice and not use of telehealth.
Among the five EMS providers who indicated there is an expected structure for handoffs, three mentioned SBAR/SBAR similar, one mentioned SPA, one said that it does not matter as long as it is consistent, and one did not provide additional details.
Lastly, most reported receiving training on handoffs both on the job and in the classroom as part of initial training (77%), and all EMS providers felt they were prepared or very prepared to give an effective handoff to ED providers.
|Table 3. EMS provider perceptions of EMS to ED handoffs|
|n (%) or mean (sd)||EMS provider|
|Quality of most recent handoff|
|Did not meet expectations||3 (13.6%)|
|Met expectations||17 (77.3%)|
|Exceeded expectations||2 (9.1%)|
|Percentage of handoffs containing the minimum key information1||67.5 (39.5)|
|Low (0-33%)||6 (27.3%)|
|Medium (34-74%)||2 (9.1%)|
|High (75-100%)||14 (63.6%)|
|EMS to ED handoffs current focus of quality improvement at organization, n (% yes)||12 (54.6%)|
|Structured handoffs2, n (% yes)||5 (23.8%)|
|Mobile telehealth used prior to EMS handoff3, n (% yes)||3 (13.6%)|
|Education source on handoffs|
|On the job||2 (9.1%)|
|How well prepared do you consider yourself to give an effective handoff to emergency department providers?|
|Not well prepared||0 (0.0%)|
|Very well prepared||11 (50.0%)|
|Notes. 1Minimum key information such as vital signs, treatment interventions, and time of symptoms in written or electronic form (not including verbal), 2EMS question reads, “Does your organization expect handoffs to be structured?” while ER provider question reads, “Do you believe there is a structure to the handoffs given from EMS?”, 3See text for details, not all of these might actually count as mobile telehealth.|
Association between years of experience, number of handoffs, and key information (Table 4):
The percentage of handoffs containing key information did not differ by the years of experience that the provider had or the number of handoffs they completed in the past month.
|Table 4. Comparing the percentage of handoffs containing key information1 by years of experience and the number of handoffs completed in the past month|
|Years of experience||.842|
|1-10 years||8||3 (37.5%)||5 (62.5%)|
|11-19 years||8||2 (25.0%)||6 (75.0%)|
|20+ years||6||1 (16.7%)||5 (83.3%)|
|Number of handoffs in the past month||.309|
|<10 handoffs||8||1 (12.5%)||7 (87.5%)|
|10-19 handoffs||9||4 (44.4%)||5 (55.6%)|
|20+ handoffs||5||1 (20.0%)||4 (80.0%)|
|Years of experience||.719|
|1-10 years||7||2 (28.6%)||5 (71.4%)|
|11-19 years||7||3 (42.9%)||4 (57.1%)|
|20+ years||16||8 (50.0%)||8 (50.0%)|
|Number of handoffs in the past month||1.000|
|<10 handoffs||7||3 (42.9%)||4 (57.1%)|
|10-19 handoffs||6||3 (50.0%)||3 (50.0%)|
|20+ handoffs||17||7 (41.2%)||10 (58.8%)|
|Notes. 1Minimum key information such as vital signs, treatment interventions, and time of symptoms in written or electronic form (not including verbal), *p-values are from Fisher’s exact tests.|
Suggestions to improve handoffs from EMS to ED providers: The following themes occurred in the suggestions to improve handoffs from the ED providers and the EMS providers. The themes were similar for the two groups, and so the results are presented together.
Consistent, structured and concise communication of key information by EMS to the ED providers. Multiple EMS and ED providers mentioned that consistency in presenting key information to the ED providers would be helpful to improve handoffs (n=4 ED providers, n=3 EMS). For example, one ED provider suggested using a state-wide written template given to the EMS personnel upon arrival, while another suggested using a standard structured format such as VOMIT or MIST. A couple of ED providers recommended the verbal presentation be succinct. An EMS provider suggested using a “cheat sheet” to help EMS make sure they remember to communicate key information.
“Structured verbal handoffs are just fine, but if we had a statewide template that could be given to the ED with vitals, blood sugar, etc on it that would be useful.” – ED provider
One ED provider and two EMS providers suggested general improved communication from the EMS to the ED providers prior to arrival. Another EMS provider mentioned that if a hospital does not use a radio system, it is much harder for them to reach the ED prior to arrival.
“ER staff responding quicker to radio request. Have 1 facility that will not use radio; delays patient information as have to use cell phone and go through prompts to get to ED staff.” – EMS provider
Active listening by the ED staff. There were several mentions by both EMS (n=4) and ED providers (n=2) that improved active listening by the ED providers while the EMS give their presentation during the handoff is needed. Additionally, one EMS provider recommended making sure that ED staff understand the importance of the handoff report from EMS.
“It’d be nice if the receiving providers actually listened to anything we had to say” – EMS provider
One ED provider suggested that the process of transitioning the patient to the ED cart from the stretcher should be formalized so that it doesn’t distract from the presentation by EMS. To solve this issue, one ED provider described a “time-out” procedure they use to encourage active listening.
“ED staff (especially in critical cases) will start reaching for the patient and starting treatments while EMS is giving report. We have instituted a ‘time-out for EMS’ when patients come to our stabilization rooms. Unless the patient needs immediate treatment or in arrest, ED staff are to leave the patient on the EMS stretcher and listen to the report being given by EMS.” – ED provider
The report from EMS needs to end up with the correct ED provider in a timely manner. There were several mentions that the verbal and/or written reports from the EMS are not always received by the relevant ED provider. One ED provider mentioned he is often receiving the handoff report 3rd hand. Another ED provider mentioned it is difficult to find the written report. EMS providers expressed similar concerns. One EMS provider mentioned that sometimes there is nobody to answer their pre-arrival radio call at the hospital. Finally, a couple of ED providers mentioned that the timeliness of receiving the report needs improvement.
“EMS to value to take the time for a complete verbal handoff to both nursing and physicians. Many times I go hunt them down because they only give report to the nurses. Then I am getting info 3rd hand. Not as good. Plus I often have questions EMS can answer but might not be part of their report.” – ED provider
“Ambulance to hospital report prior to arrival should be given to nurse/provider who will be meeting the arriving ambulance and providing patient care. So many times the report doesn’t make it or is so scrambled by the time the ambulance arrives to the ED.” – EMS provider
“We have talked with Meds-1 extensively about the need for timely written/electronic information to be available at handoff but they continue to be resistant to change. Currently we only get a written report forwarded electronically within 48 hours.” – ED provider
Integrate the pre-arrival information into the EMR at the receiving hospital. One suggestion for improving communication and getting the report to the correct ED provider was to integrate the pre-arrival information into the EMR at the receiving hospital. This was mentioned by one EMS and two ED providers.
“The ability for EMS chart to go directly into the charting of the receiving hospital.” – EMS provider
ED providers to treat EMS providers with respect and gratitude. One EMS provider and one ED provider pointed out that the EMS providers should be treated with respect and gratitude, understanding that they are often in a volunteer role with limited resources.
“ED provider to treat EMS persons with respect and gratitude. Make them feel that their contribution is appreciated. In our system, EMS are usually volunteer. A thank you and a pat on the back goes a long way to motivate those volunteers.” – ED provider
“The ER nurse needs to be understanding with the limited resources that a volunteer has and it may not be exactly packaged like they want but it is what we did with the time and people we have in the back of an ambulance.” – EMS provider
In this cross-sectional study, both the ED providers and EMS thought the quality of their most recent handoff met their expectations; however, key information was still missing some of the time. This was true regardless of location or years of experience. Very few ED providers noted that the EMS to ED handoff is a part of a QI project at their organization, but many EMS and ED providers had ideas for how to improve the handoff process.
In general, EMS personnel felt prepared to deliver a quality handoff. As a result of the limited generalizability of the quantitative results (especially for EMS), the open-ended/qualitative results may be of more impact to focus on in future larger research projects and QI initiatives. Future research could include nurse’s opinions of EMS to ED handoffs as they receive the vast majority of handoffs form EMS.
This study had several limitations. First, EMS providers and ED providers are not necessarily from the same hospital system, and so we are unable to match them to see if their experience is similar/different within a system. Second, a small sample size means that we likely cannot generalize the experience to all EMS/ED providers in Minnesota. We may be limited in the number of subgroup comparisons we can do. Third, due to small sample size, the results were mostly descriptive, rather than inferential. Fourth, the EMS provider responses were all only from one region of Minnesota (a rural area), limiting the generalizability of the results for that survey.
It is possible that several of these EMS providers are from the same organization, thus their responses only represent the one organization. Fifth, while EMS providers may be from only a few organizations, ED providers come from several different organizations, thus comparing the quantitative results directly between the two groups was not appropriate. Sixth, in EMS rating the quality of the most recent handoff, they could either interpret this question as rating their own performance, or as the interaction with ED providers. Seventh, employment FTE was not addressed in the survey and could provide more insight into the depth of experience each healthcare worker had, more so than years of experience.
Among EMS and ED providers surveyed in the state of Minnesota, most feel the most recent handoff between them met their expectations, regardless of years of experience or location of employment. However, in some handoffs key information was still missing and this gap is an opportunity for improvement. Several ideas for improving handoffs were suggested such as consistent, structured and concise communication from EMS to ED providers in a timely manner.
Above all, and regardless of the quantitative analysis as presented, both ED and EMS providers agree that the most important aspect of the patients transfer process and communication process is mutual respect and active listening with feedback and collaboration.
We thank Lynsie Radovich, PhD for helping with REDCap and project guidance. Sandra Stover, MD helped with project guidance, direction and securing funding for the data analysis.
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