Goldberg SA, Porat A, Strother CG, et al. Quantitative analysis of the content of EMS handoff of critically ill and injured patients to the emergency department. Prehosp Emerg Care. 2017;21(1):14-17.
This study occurred in a large, busy inner-city ED that sees more than 100,000 patients annually. Over the course of a few months, the bedside patient handoff (report) of critically ill and injured patients was recorded by anonymous scribes and audio recorded for later review. Neither the medical staff nor the EMS providers were aware that the handoff was being monitored.
Ninety patient handoffs were evaluated. EMS providers relayed the patient’s chief complaint 78% of the time. The patient’s initial presentation was reported in 57% of handoffs and a complete set of vital signs in 47% of reports. EMS providers gave an overall assessment of the patient’s condition in only 31% of handoffs. Paramedics were significantly more likely than EMTs to report each of the handoff components.
The authors concluded that their study confirmed the previously reported poor quality of EMS handoff and “demonstrates the need for further training in the provision of patient handoff.”
Doc Wesley Comments
When I first read this paper, all I could think is how this might be considered “ambush research,” where performance is evaluated by unknown individuals and then scrutinized without consideration for the quality of care provided. But then I realized that this study had nothing to do with the quality of care.
As is accurately reflected in its title, this study monitored nothing more than whether each of the components of the patient handoff occurred.
Is that the whole story? I don’t think so. The researchers didn’t give credit to EMS providers if they gave anything less than all the vital signs, including heart rate, respiratory rate, blood pressure and oxygen saturation. But are all these vital signs required when handing off a critical patient, or only those that are pertinent?
But I get it. This study was only about quantity. But perhaps the quantity of information that the authors felt was essential is a rather high expectation in the real world. Why not survey the physicians and nurses to determine their satisfaction with the report?
Additionally, if the researchers already suspected they would duplicate the finding of others, why not make a change in their process to also determine the quality of the information provided?
For example, many of my receiving hospitals use a process called “Time Out,” where, while moving the patient from the stretcher to the bed, the ED staff is quiet and the rescuers give their report. Without any interruption, EMTs and paramedics follow the acronym MIVT (mechanism, initial findings, vital signs, and treatment) when giving their report. Once finished, the ED staff can then ask questions.
Having this type of structured handoff, which ensures everyone is quiet and listening, not only demonstrates respect of EMS providers and the prehospital report but also improves the quality of the report by assuring that the most important facts are relayed.
Medic Wesley Comments
Effective communication is a skill that falls short in every aspect of emergency services. The ED handoff is no different. When radio reports are given, time is limited and the EMS caregiver is busy providing care in a less than optimal environment. But while speaking face-to-face, it seems it should be easier to close the communication loop.
At the time the patient handoff and report are given, there should be give and take in the conversation. No one should walk away feeling that they should’ve learned more about the patient.
All caregivers involved in the handoff of patient care need to understand that it’s not a test to see if there are omissions. Perhaps since EMS didn’t experience the receiving facility asking pertinent questions, they weren’t aware of all the information that was needed or expected. When EMS providers are regularly asked specific questions following their transfer of care, they often add that information to future reports.
Likewise, EMS shouldn’t assume that just because the receiving facility didn’t ask questions that there isn’t additional information that would be helpful. “Do you have any questions?” or, “Have I left anything out?” are two little sentences that can help providers give a more complete patient handoff report.
If hospital staff aren’t getting enough information from the EMS crew, I see this as an education and training opportunity for all involved, not just EMS.
Learning the importance of relaying and obtaining patient information can develop and perhaps improve relationships within the patient care team.
It’s working together that makes us good patient advocates.