Information loss in emergency medical services handover of trauma patients

Accuracy of emergency medical services-reported last known normal times in patients suspected with acute stroke

BACKGROUND AND PURPOSE

The last known normal (LKN) time is a critical determinant of IV tissue-type plasminogen activator (IV tPA) eligibility; however, the accuracy of emergency medical services (EMS)-reported LKN times is unknown. We determined the congruence between neurologist-determined and EMS-reported LKN times and identified predictors of incongruent LKN times.

METHODS

We prospectively collected EMS-reported LKN times for patients brought into the emergency department with suspected acute stroke and calculated the absolute difference between the neurologist-determined and EMS-reported LKN times (|ΔLKN|). We determined the rate of inappropriate IV tPA use if EMS-reported times had been used in place of neurologist-determined times. Univariate and multivariable linear regression assessed for any predictors of prolonged |ΔLKN|.

RESULTS

Of 251 patients, mean and median |ΔLKN| were 28 and 0 minutes, respectively. |ΔLKN| was <15 minutes in 91% of the entire cohort and <15 minutes in 80% of patients with a diagnosis of stroke (n=86). Of patients who received IV tPA, none would have been incorrectly excluded from IV tPA if the EMS LKN time had been used. Conversely, of patients who did not receive IV tPA, 6% would have been incorrectly included for IV tPA consideration had the EMS time been used. In patients with wake-up stroke symptoms, EMS underestimated LKN times: mean neurologist LKN time-EMS LKN time=208 minutes. The presence of wake-up stroke symptoms (P<0.0001) and older age (P=0.019) were independent predictors of prolonged |ΔLKN|.

CONCLUSIONS

EMS-reported LKN times were largely congruent with neurologist-determined times. Focused EMS training regarding wake-up stroke symptoms may further improve accuracy.

Face-to-face handoff: improving transfer to the pediatric intensive care unit after cardiac surgery

The goal was to develop and implement a comprehensive, primarily face-to-face handoff process that begins in the operating room and concludes at the bedside in the intensive care unit (ICU) for pediatric patients undergoing congenital heart surgery. Involving all stakeholders in the planning phase, the framework of the handoff system encompassed a combination of a formalized handoff tool, focused process steps that occurred prior to patient arrival in the ICU, and an emphasis on face-to-face communication at the conclusion of the handoff. The final process was evaluated by the use of observer checklists to examine quality metrics and timing for all patients admitted to the ICU following cardiac surgery. The process was found to improve how various providers view the efficiency of handoff, the ease of asking questions at each step, and the overall capability to improve patient care regardless of overall surgical complexity.

Electronic Prehospital Records are Often Unavailable for Emergency Department Medical Decision Making

INTRODUCTION

To determine emergency physician (EP) opinions of prehospital patient care reports (PCRs) and whether such reports are available at the time of emergency department (ED) medical decision-making.

METHODS

Prospective, cross-sectional, electronic web-based survey of EPs regarding preferences and availability of prehospital PCRs at the time of ED medical decision-making.

RESULTS

We sent the survey to 1,932 EPs via 4 American College of Emergency Physicians (ACEP) email lists. As a result, 228 (11.8%) of email list members from 31 states and the District of Columbia completed the survey. Most respondents preferred electronic prehospital PCRs as opposed to handwritten prehospital PCRs (52.2% [95% confidence interval (CI): 49.1, 55.3] vs. 17.1% [95%CI: 11.7, 22.5]). The remaining respondents (30.5% [95%CI: 26.0, 35.0]) had no preference or had seen only one type of PCR. Of the respondents, 45.6% [95%CI: 42.1, 48.7] stated PCRs were "very important" while 43.0% [95% CI: 39.3, 46.7] rated PCRs as "important" in their ED practice. Most respondents (79.6% [95%CI: 76.5, 82.7]) reported electronic prehospital PCRs were available ≤50% of the time for medical decision-making while 20.4% [95%CI: 9.2, 31.6] reported that electronic prehospital PCRs were available > 50% of the time (P=0.00). A majority of participants (77.6% [95%CI: 74.5, 80.7]) reported that handwritten prehospital PCRs were available ≥ 50% while 22.4% [95%CI: 11.8, 33.0] of the time for medical decision-making (P=0.00).

CONCLUSION

EPs in this study felt that prehospital PCRs were important to their ED practice and preferred electronic prehospital PCRs over handwritten PCRs. However, most electronic prehospital PCRs were unavailable at the time of ED medical decision-making. Although handwritten prehospital PCRs were more readily available, legibility and accuracy were reported concerns. This study suggest that strategies should be devised to improve the overall accuracy of PCRs and assure that electronic prehospital PCRs are delivered to the receiving ED in time for consideration in ED medical decision-making.

Review article: Improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient

Clinical communication and recognising and responding to a deteriorating patient are key current patient safety issues in healthcare. The aim of this literature review is to identify themes associated with aspects of the hospital clinical handover between paramedics and ED staff that can be improved, with a specific focus on the transfer of care of a deteriorating patient. Extensive searches of scholarly literature were conducted using the main medical and nursing electronic databases, including Cumulative Index to Nursing and Allied Health Literature, Medline and PubMed, during 2011 and again in July 2012. Seventeen peer-reviewed English-language original quantitative and qualitative studies from 2001 to 2012 were selected and critically appraised using an evaluation tool based on published instruments. Relevant themes identified were: professional relationships, respect and barriers to communication; multiple or repeated handovers; identification of staff in the ED; significance of vital signs; need for a structured handover tool; documentation and other communication methods and education and training to improve handovers. The issues raised in the literature included the need to: produce more complete and concise handovers, create respectful and effective communication, and identify staff in the ED. A structured handover tool such as ISBAR (a mnemonic covering Introduction, Situation, Background, Assessment and Recommendations) would appear to provide a solution to many of these issues. The recording of vital signs and transfer of these data might be improved with better observation systems incorporating early warning strategies. More effective teamwork could be achieved with further clinical communications training.

Handover of patients: a topical review of ambulance crew to emergency department handover

Handover has major implications for patient care. The handover process between ambulance and emergency department (ED) staff has been sparsely investigated. The purpose of this paper is, based on a literature review, to identify and elaborate on the major factors influencing the ambulance to ED handover, and to bring suggestions on how to optimize this process. A literature search on handovers to EDs was performed in PubMed, Embase, Web of Science and Cochrane databases. A total of 18 papers were included. Issues regarding transfer of information are highlighted. Newer studies suggest that implementing a structured handover format holds the possibilities for improving the process. Electronic equipment could play a part in reducing problems. Cultural and organizational factors impact the process in different ways. The professions perceive the value and quality of information given differently. Giving and taking over responsibility is an important issue. The handover of patients to the ED has the potential to be improved. Cultural issues and a lack of professional recognition of handover importance need to be approached. Multidisciplinary training in combination with a structured tool may have a potential for changing the culture and improving handover.

Should air medical patients be transferred on helipad or trauma bay?

OBJECTIVE

Helicopter emergency medical services (HEMS) are widely used in regional trauma care and present unique challenges in the patient handoff process. In particular, the practice of patient handoff on the landing zone versus the trauma bay does not exist in ground emergency medical services. We hypothesized that patients handed off on the landing zone versus the trauma bay would have different patient characteristics and outcomes.

METHODS

A retrospective review identified 305 HEMS trauma patients received at our level 1 trauma center over a 3-year period. Patients were sorted on the basis of the handoff location, (landing zone vs. trauma bay) and assessed for predictors of injury severity including the Revised Trauma Score, the Injury Severity Score, the Trauma and Injury Severity Score, and other outcomes, primarily mortality.

RESULTS

Of the 305 patients, 235 (77%) were handed off in the bay, and 70 (23%) were not. Regarding the characteristics of patients who were handed off in the bay, they were more likely to have hypotension (100% vs. 73%), have a lower O(2) saturation level (97.9 vs. 99.4), and a lower Glasgow Coma Scale at the scene (10.9 vs. 13.9.). When controlling for injury severity, the odds of survival for patients who were handed off in the bay were 11.06 times the odds for patients who were not handed off in the bay.

CONCLUSION

In this limited study, we found that HEMS did identify the sickest patients and brought them to the trauma bay. Despite their greater injury severity, the patients handed off in the bay fared better than those handed off on the landing zone.

Exclusion of context knowledge in the development of prehospital guidelines: results produced by realistic evaluation

Background

Prehospital work is accomplished using guidelines and protocols, but there is evidence suggesting that compliance with guidelines is sometimes low in the prehospital setting. The reason for the poor compliance is not known. The objective of this study was to describe how guidelines and protocols are used in the prehospital context.

Methods

This was a single-case study with realistic evaluation as a methodological framework. The study took place in an ambulance organization in Sweden. The data collection was divided into four phases, where phase one consisted of a literature screening and selection of a theoretical framework. In phase two, semi-structured interviews with the ambulance organization's stakeholders, responsible for the development and implementation of guidelines, were performed. The third phase, observations, comprised 30 participants from both a rural and an urban ambulance station. In the last phase, two focus group interviews were performed. A template analysis style of documents, interviews and observation protocols was used.

Results

The development of guidelines took place using an informal consensus approach, where no party from the end users was represented. The development process resulted in guidelines with an insufficiently adapted format for the prehospital context. At local level, there was a conscious implementation strategy with lectures and manikin simulation. The physical format of the guidelines was the main obstacle to explicit use. Due to the format, the ambulance personnel feel they have to learn the content of the guidelines by heart. Explicit use of the guidelines in the assessment of patients was uncommon. Many ambulance personnel developed homemade guidelines in both electronic and paper format. The ambulance personnel in the study generally took a positive view of working with guidelines and protocols and they regarded them as indispensable in prehospital care, but an improved format was requested by both representatives of the organization and the ambulance personnel.

Conclusions

The personnel take a positive view of the use of guidelines and protocols in prehospital work. The main obstacle to the use of guidelines and protocols in this organization is the format, due to the exclusion of context knowledge in the development process.

Data recording aids in acute admissions

PURPOSE

Clinical data capture and transfer are becoming more important as hospital practices change. Medical record pro-formas are widely used but their efficacy in acute settings is unclear. This paper aims to assess whether pro-forma and aide-memoire recording aids influence data collection in acute medical and surgical admission records completed by junior doctors.

DESIGN/METHODOLOGY/APPROACH

During October 2007 to January 2008, 150 medical and 150 surgical admission records were randomly selected. Each was analysed using Royal College of Physicians guidelines. Surgical record deficiencies were highlighted in an aide-memoire printed on all A4 admission sheets. One year later, the exercise was repeated for 199 admissions.

FINDINGS

Initial assessment demonstrated similar data capture rates, 77.4 per cent and 75.9 per cent for medicine and surgery respectively (Z = -0.74, p = 0.458). Following the aide-memoire's introduction, surgical information recording improved relatively, 70.5 per cent and 73.9 per cent respectively (Z = 2.01, p = 0.045). One from 11 aide-memoire categories was associated with improvement following clinical training. There was an overall fall in admission record quality during 2008-9 vs 2007-8.

RESEARCH LIMITATIONS/IMPLICATIONS

The study compared performance among two groups of doctors working simultaneously in separate wards, representing four months' activity.

PRACTICAL IMPLICATIONS

Hospital managers and clinicians should be mindful that innovations successful in elective clinical practice might not be transferable to an acute setting.

ORIGINALITY/VALUE

This audit shows that in an acute setting, over one-quarter of clinical admission data were not captured and devices aimed at improving data capture had no demonstrable effect. The authors suggest that in current hospital practice, focussed clinical training is more likely to improve patient admission records than employing recording aids.

Network analysis of team communication in a busy emergency department

Background

The Emergency Department (ED) is consistently described as a high-risk environment for patients and clinicians that demands colleagues quickly work together as a cohesive group. Communication between nurses, physicians, and other ED clinicians is complex and difficult to track. A clear understanding of communications in the ED is lacking, which has a potentially negative impact on the design and effectiveness of interventions to improve communications. We sought to use Social Network Analysis (SNA) to characterize communication between clinicians in the ED.

Methods

Over three-months, we surveyed to solicit the communication relationships between clinicians at one urban academic ED across all shifts. We abstracted survey responses into matrices, calculated three standard SNA measures (network density, network centralization, and in-degree centrality), and presented findings stratified by night/day shift and over time.

Results

We received surveys from 82% of eligible participants and identified wide variation in the magnitude of communication cohesion (density) and concentration of communication between clinicians (centralization) by day/night shift and over time. We also identified variation in in-degree centrality (a measure of power/influence) by day/night shift and over time.

Conclusions

We show that SNA measurement techniques provide a comprehensive view of ED communication patterns. Our use of SNA revealed that frequency of communication as a measure of interdependencies between ED clinicians varies by day/night shift and over time.

Usage of documented pre-hospital observations in secondary care: a questionnaire study and retrospective comparison of records

BACKGROUND

The patient handover is important for the safe transition from the pre-hospital setting to secondary care. The loss of critical information about the pre-hospital phase may impact upon the clinical course of the patient.

METHODS

University Hospital Emergency Care registrars answered a questionnaire about how they perceive clinical documentation from the ambulance services. We also reviewed patient records retrospectively, to investigate to what extent eight selected parameters were transferred correctly to hospital records by clinicians. Only parameters outside the normal range were selected.

RESULTS

The registrars preferred a verbal handover with hand-written pre-hospital reports as the combined source of clinical information. Scanned report forms were infrequently used. Information from other doctors was perceived as more important than the information from ambulance crews. Less than half of the selected parameters in pre-hospital notes were transferred to hospital records, even for parameters regarded as important by the registrars. Abnormal vital signs were not transferred as often as mechanism of injury, medication administered and immobilisation of trauma patients.

CONCLUSIONS

Data on pre-hospital abnormal vital signs are frequently not transferred to the hospital admission notes. This information loss may lead to suboptimal care.

Operative length independently affected by surgical team size: data from 2 Canadian hospitals

BACKGROUND

Knowledge of the composition of a surgical team is the premise for studying efficiency inside the operating room.

METHODS

To investigate the team composition in general surgery procedures, we retrospectively reviewed procedures performed by an expert general surgeon in 2007-08 at 2 tertiary hospitals. For each patient, demographic characteristics, procedure type, team members and procedure length were extracted from intraoperative nursing records. We assessed procedure complexity using a calculated index. Multiple logistic regressions were performed to assess the association between procedure length and team size after adjusting for procedure complexity and patient condition.

RESULTS

For the 587 procedures reviewed, the mean procedure length was 88 (standard deviation [SD] 51) minutes. On average, 8 team members (range 4-14), including surgeons, anesthesiologists, nurses and other specialists, were involved in each procedure. Only 47 (8%) procedures were performed by 1 surgeon. Most were performed by 2 (295 [50%]) or 3 surgeons (214 [36%]). Half the team members were nurses (mean 4, range 1-7). Both the complexity of the operation and the team size affected the procedure length significantly. When procedure complexity and patient condition were constant, adding 1 team member predicted a 7-minute increase in procedure length.

CONCLUSION

This study demonstrates that a frequent change of core team members has a negative impact on surgical performance. Management strategies need to improve to optimize team efficiency in the operating room.

Physical therapy on the wards after early physical activity and mobility in the intensive care unit

BACKGROUND

Weakness and debilitation are common following critical illness. Studies that assess whether early physical activity initiated in the intensive care unit (ICU) continues after a patient is transferred to a ward are lacking.

OBJECTIVE

The purpose of this study was to assess whether physical activity and mobility initiated during ICU treatment were maintained after patients were discharged from a single ICU to a ward.

DESIGN

This was a cohort study.

METHODS

Consecutive patients who were diagnosed with respiratory failure and admitted to the respiratory ICU (RICU) at LDS Hospital underwent early physical activity and mobility as part of usual care. Medical data, the number of requests for a physical therapy consultation or nursing assistance with ambulation at ICU discharge, and mobility data were collected during the first 2 full days on the ward.

RESULTS

Of the 72 patients who participated in the study, 65 had either a physical therapy consultation or a request for nursing assistance with ambulation at ward transfer. Activity level decreased in 40 participants (55%) on the first full ward day. Of the 61 participants who ambulated 100 ft (30.48 m) or more on the last full RICU day, 14 did not ambulate, 22 ambulated less than 100 ft, and 25 ambulated 100 ft or more on the first ward day.

LIMITATIONS

Limitations include lack of data regarding why activity was not performed on the ward, lack of longitudinal follow-up to assess effects of activity, and lack of generalizability to patients not transferred to a ward or not treated in an ICU with an early mobility program.

CONCLUSIONS

Despite the majority of participants having a physical therapy consultation or a request for nursing assistance with ambulation at the time of transfer to the medical ward, physical activity levels decreased in over half of participants on the first full ward day. The data suggest a need for education of ward staff regarding ICU debilitation, enhanced communication among care providers, and focus on the importance of patient-centered outcomes during and following ICU treatment.

Patient safety in emergency medical services: a systematic review of the literature

BACKGROUND

Preventable harm from medical care has been extensively documented in the inpatient setting. Emergency medical services (EMS) providers care for patients in dynamic and challenging environments; prehospital emergency care is a field that represents an area of high risk for errors and harm, but has received relatively little attention in the patient safety literature.

OBJECTIVE

To identify the threats to patient safety unique to the EMS environment and interventions that mitigate those threats, we completed a systematic review of the literature.

METHODS

We searched MEDLINE, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) for combinations of key EMS and patient safety terms composed by a pan-canadian expert panel using a year limit of 1999 to 2011. We excluded commentaries, opinions, letters, abstracts, and non-english publications. Two investigators performed an independent hierarchical screening of titles, abstracts, and full-text articles blinded to source. We used the kappa statistic to examine interrater agreement. Any differences were resolved by consensus.

RESULTS

We retrieved 5,959 titles, and 88 publications met the inclusion criteria and were categorized into seven themes: adverse events and medication errors (22 articles), clinical judgment (13), communication (6), ground vehicle safety (9), aircraft safety (6), interfacility transport (16), and intubation (16). Two articles were randomized controlled trials; the remainder were systematic reviews, prospective observational studies, retrospective database/chart reviews, qualitative interviews, or surveys. The kappa statistics for titles, abstracts, and full-text articles were 0.65, 0.79, and 0.87, respectively, for the first search and 0.60, 0.74, and 0.85 for the second.

CONCLUSIONS

We found a paucity of scientific literature exploring patient safety in EMS. Research is needed to improve our understanding of problem magnitude and threats to patient safety and to guide interventions.

The effectiveness of high fidelity simulation on medical-surgical registered nurses' ability to recognise and respond to clinical emergencies

BACKGROUND

There is a paucity of evidence regarding the efficacy in preparing medical-surgical nurses to respond to patients with acutely deteriorating conditions.

STUDY AIM

The aim of this study was to evaluate registered nurses' ability to respond to the deteriorating patient in clinical practise following training using immersive simulation and use of a high fidelity simulator.

METHODS

This study was a follow-up survey of medical-surgical graduate nurses following immersive high fidelity simulation training. Thirty eight registered nurses practising in medical-surgical areas completed the simulation as part of university graduate study. A follow-up survey of the graduate medical-surgical registered nurses conducted three months following completion of a high fidelity simulation-based learning experience. Outcomes consisted of the number of times skills were used in practise and the usefulness of simulation in preparing for actual emergency events.

RESULTS

Participants reported a total of 164 clinical patient emergencies in the follow-up time period including: 46% cardiac, 32% respiratory, 10% neurological, 7% cardiac arrest and 5% related to electrolyte disturbances. The ability to respond in a systematic way, handover to the emergency team and airway management were identified as the skills most improved during patient emergencies following simulation. The most useful aspects of the simulation experience identified were scenario debriefing and assertiveness training. Participants with less years of clinical experience were more likely to report practising the team leader role and debriefing as the most useful aspects of simulation.

CONCLUSIONS

The skills practised in simulation were highly relevant to participants practise in medical-surgical areas. Non-technical skills, including assertiveness skills should be considered in future emergency training courses for nurses.

Adaptation of a postoperative handoff communication process for children with heart disease: a quantitative study

Handoff communication is a point of vulnerability when valuable patient information can be inaccurate or omitted. An institutional protocol was implemented in 2005 to improve the handoff from the operating room to the intensive care unit after pediatric cardiac surgery. A cross-sectional study of the present process was performed to understand how users adapt a communication intervention over time. Twenty-nine handoff events were observed. Individuals required for the handoff were present at 97% of the events. Content items averaged a 53% reporting rate. Some clinical information not specified in the protocol demonstrated a higher reporting rate, such as echocardiogram results (68%) and vascular access (79%). A mean of 2.3 environmental distractions per minute of communication were noted. Participant-directed adjustments in content reporting suggest that a facilitator in process improvement is user-centered innovation. Future handoff communication interventions should reduce nonessential distractions and incorporate a discussion of the anticipated patient course.

The performance and assessment of hospital trauma teams

The purpose of the trauma team is to provide advanced simultaneous care from relevant specialists to the seriously injured trauma patient. When functioning well, the outcome of the trauma team performance should be greater than the sum of its parts. Trauma teams have been shown to reduce the time taken for resuscitation, as well as time to CT scan, to emergency department discharge and to the operating room. These benefits are demonstrated by improved survival rates, particularly for the most severely injured patients, both within and outside of dedicated trauma centres. In order to ensure the best possible performance of the team, the leadership skills of the trauma team leader are essential and their non-technical skills have been shown to be particularly important. Team performance can be enhanced through a process of audit and assessment of the workings of the team and the evidence currently available suggests that this is best facilitated through the process of video review of the trauma resuscitation. The use of human patient simulators to train and assess trauma teams is becoming more commonplace and this technique offers a safe environment for the future education of trauma team staff.

Trauma teams are a key component of most programmes which set out to improve trauma care. This article reviews the background of trauma teams, the evidence for benefit and potential techniques of performance assessment. The review was written after a PubMed, Ovid, Athens, Cochrane and guideline literature review of English language articles on trauma teams and their performance and hand searching of references from the relevant searched articles.