Author Tony Fernandez will discuss this month's column during the PCRF Journal Club podcast on Monday, April 10, at 12 pm CT. Register here.
This is the second entry in a new series called The Trip Report: Turning Research Into Practice. Watch for it regularly. Find the opening column at www.emsworld.com/12303973.
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. Preh Emerg Care, 2017 Jan–Feb; 21(1): 14–17.
This month's topic is patient safety. In 2014 the American College of Emergency Physicians highlighted the importance of appropriate patient handoffs in improving patient safety. There has been some previous research looking into such transitions. Barriers to a successful handoff have been identified, and areas where communication breakdowns occur have been discussed. However, most previous research hasn't specifically evaluated what information was delivered by the EMS provider to the ED physician. The authors of this recently published study performed a quantitative analysis of information delivered from the EMS provider to the ED physician during transfer of care for critically ill or injured patients. A quantitative analysis is another way to say the study counted things, in this case information delivered during a patient handoff.
This study looked at handoffs of the "sickest" of patients—those brought directly to the ED resuscitation area upon EMS arrival. The patients included those with increased trauma classifications, suspected sepsis, hemodynamic instability, suspected cerebral ischemia or ST-segment elevation myocardial infarction.
The study period was relatively short, three months during 2013. However, because this study took place in an urban academic medical center that sees more than 100,000 patients a year, investigators were able to assess 97 of these very sick patients during the study. One strength of this study was that they recorded the handoffs. This is important because even though the study team employed research assistants to document the handoffs, they could go back to the recording and make sure they captured and analyzed all the correct information.
One interesting note was that the research assistants were instructed to be as inconspicuous as possible. Both the EMS providers and the ED physicians were blinded to the study design. In other words, they were likely made aware that a study was taking place, but the goals of the study were not shared with the EMS providers or the ED physicians. This also helped the study design because it is reasonable to think an EMS provider might modify how they typically deliver information to the ED physician if they knew they were being recorded. This is actually called the Hawthorne effect: that individuals will modify their behavior simply because they are being watched. So the authors made a good effort to reduce this bias.
This study looked exclusively at patient handoffs and did not collect data on patient demographics. The items the study team assessed for inclusion in the handoff were the patient's age and chief concern; a provider assessment of the patient's initial presentation; a set of vital signs; capillary blood glucose measurement; pertinent physical exam findings; the patient's relevant past medical, allergy and medication history; and an overall assessment of the patient's condition.
Of the 97 patients included, two-thirds were transported by private ambulance companies, and one-third by a fire-based service. The large majority (83%) were 9-1-1 responses. About two-thirds of the handoffs were from paramedics, and the remainder were from providers "at the EMT level." It is unclear from the study if this included just Basics or if Intermediates/advanced EMTs were included.
The authors first assessed every handoff and determined that the EMS provider included a chief complaint in 78% of them. EMS also included a description of the scene in 58% of handoffs. Less than 60% included a complete set of vital signs. Less than 50% included pertinent physical exam findings or a medical history. Finally the EMS provider included an assessment of the patient's clinical status in just 31% of cases.
Next the authors looked for differences in information delivered based on the EMS provider's certification level, the call type (9-1-1 or interfacilty transfer) and the agency type (private or fire-based). When comparing the information delivered by certification level, they found no difference in the amount of time, age, chief complaint, initial presentation, past medical history and allergy information delivered during the handoff. However, the authors found that paramedics were statistically more likely to provide a complete set of vitals, overall assessment, medication history and physical exam findings.
The only two differences were noted when comparing call types: EMS providers working 9-1-1 responses were more likely to deliver a complete set of vital signs and physical exam findings. Authors found no differences when comparing fire-based EMS to privates.
Many of these findings, on their face, seem to suggest EMS providers are not delivering sufficient information during patient handoffs. It is important to note that the patients included in this study were critically ill or injured. The authors assessed the sickest patients EMS cares for, and as such, the need for a rapid handoff with limited information is certainly possible among these patients. However, there are many important variables that were not assessed in this study that also could relate to the amount of information delivered. Most notably the authors indicated in their introduction that previous research has identified barriers to delivering an appropriate patient handoff. These barriers include limited time, distractions and gaps in communication. None of these barriers were assessed in this study. This study also did not assess how the quantity of information provided in a handoff related to the patient's outcome.
While this study has some clear limitations, it is said that one can't improve a process unless it can be measured. This study provides some baseline measurements that were not previously reported in the literature. It would be interesting to compare all levels of EMS certification. It would also be valuable to replicate this study in other environments, including rural community hospitals.
Most of us probably believe the patient handoff process in our region is not perfect, and this research can help us do our part to improve it. Next time you are transferring care, it might be helpful to make an extra effort to ensure a complete set of vitals is included. Obviously it may be difficult to include a medical history for some very sick patients, but these results suggest we should make a better effort to include the patient's clinical status and a scene description in our handoff presentations.
One of the most useful things stated in the conclusion of this manuscript is the need to have multidisciplinary training and develop a standardized approach to patient handoffs. I think we all might agree that training with local ED physicians to improve handoffs could be very beneficial. However, there is currently little research examining if this is true. So if you can do this in your area, document it, publish it and add to our collective knowledge on patient handoffs and safety.
Antonio R. Fernandez, PhD, NRP, FAHA, is research director at the EMS Performance Improvement Center and assistant professor in the Department of Emergency Medicine at the University of North Carolina–Chapel Hill.