The EMS Handoff: A Critical Time for Critical Improvement

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In the middle of a busy shift, you are hastily beckoned to a new patient’s room just as he has begun to seize. Your patient is an 8-year-old-boy dropped off by EMS as a transfer from a rural clinic. The nurse hands you an EMS trip sheet that states, “Patient found unresponsive in his home. Empty pill bottles nearby. No obvious signs of trauma. Assessed vitals and transported to care facility.” Aside from a set of vitals, additional details are sparse. Your nurse thinks the EMS providers may have mentioned which pills were found nearby; however, he was busy getting lorazepam drawn up and does not recall specifics.

As you are trying to figure out what happened to this little boy, your next patient arrives in respiratory distress on BiPAP. You are given a clear, concise, uninterrupted presentation by EMS with both nursing and physician present at bedside. You receive a printed copy of the electronic prehospital note, as well as automatic sets of vitals, an ECG, and a list of interventions with time stamps. You are grateful this crew has been thorough and complete, but as you struggle to figure out what the little boy ingested, you wonder what can be done to improve the handoff process for all patients arriving to the emergency department by EMS.

Despite unusual origins, EMS has become an absolutely essential part of patient care in the prehospital setting.1 As true first responders, their assessment and interventions have the potential to significantly alter patient outcomes, long before they arrive in an emergency department. However, variations in education, training, protocols, health information exchange, and established guidelines for a formal transfer of care often leave a lot to be desired at the time of handoff to hospital providers.

The EMS handoff is a crucial opportunity to obtain accurate information about a patient’s presenting signs and symptoms, environment, changes in status, and response to interventions. But physicians may not be present at the handoff of a critically ill patient. Such a missed opportunity can lead to potential incorrect diagnoses or inefficient care in the workup of the undifferentiated patient.

The recent ACEP policy statement, “Transfer of Patient Care Between EMS Providers and Receiving Facilities,” addresses the handoff:

In addition to a verbal report from EMS providers, the minimum key information required for patient care must be provided in written or electronic form at the time of transfer of patient care…The minimum key information reported at the time of handoff must include information that is required for optimum care of the patient – examples include vital signs, treatment interventions, and the time of symptom onset for time-sensitive illnesses.2

Other essential information may include details of the scene and the patient’s extrication, bystander reports, and clinical impressions by pre-hospital providers. These key pieces of information may help direct patient care and evaluation in the emergency department.

Rather than a single formula, however, each EMS service and each emergency department may have their own standards for appropriate transfer of care, particularly when it comes to patients of different acuity levels. In particular, high-risk handoffs should include clear and effective communication of vital information. These handoffs may benefit from algorithms such as the model proposed by the Council of Emergency Medicine Residency Directors (CORD) Transitions of Care Task Force. The popular 5-step model developed for intra-departmental handoff includes identification of high risk handoffs, uninterrupted time and space during handoff, and opportunity for questions and clarifications.3

By standardizing parts of the handoff and enabling open communication with the emergency physician in a calm and quiet environment, many potential barriers to safe handoff can be addressed.4 Of course such a standardized approach would require buy-in from both prehospital agencies and receiving hospitals, and it would need to be driven by a culture change at the administrative level. Physicians and residents involved in or interested in EMS are in an excellent position to help cultivate this change.

One of the more difficult aspects of health information transfer and review is the fractured system of health data exchange. Electronic medical records between prehospital and hospital systems are rarely integrated, and systems that allow patient follow-up and integrated chart review are exceedingly rare. While data is being compiled at a national level with some groundwork in place via the National EMS Information System (NEMSIS), useful implementation is infrequent and often with limited practical scope.5

One proposed strategy has been to develop data silos in the form of statewide or regional data to target useful implementation. One such trial in Pennsylvania linked nearly 2,700 prehospital electronic records to their counterpart hospital-based EMRs and developed a model for the infrastructure needed for prehospital comparative effectiveness research.6 In this process, the authors of the study tackled some of the biggest barriers to good data linkage, including EMS records not being uploaded, inadequate prehospital record databases, lack of data use agreements, and inability to access records outside of a health system partnership. This type of implementation has been shown to be feasible, albeit with a significant number of barriers.7 While an integrated EMR would help facilitate ideal patient care and handoff, it would also allow for more robust research on how the quality of the patient handoff actually affects patient outcomes.

In addition to evaluating patient outcomes, a key aspect of quality assurance and improvement includes process improvement, particularly in feedback. Some EMS agencies may have faculty or staff on hand working specifically in these areas. Feedback can be department-wide, or it may occur via direct feedback to a crew. In an effort to include the critical handoff, morbidity and mortality case reviews should include details of the EMS report whenever possible. Prior studies have confirmed that hospital-directed feedback improves performance during handoff, for both the EMS providers and the hospital personnel accepting the patient.8 A relationship that fosters an environment of collaboration and systems improvement on both ends will improve satisfaction and patient care.

The emergency department and prehospital care providers are often seen as innovators of health care processes. With the frequency of high acuity patient care handoffs, it falls to emergency care providers to seek strategies to improve the first and potentially most critical transfer of care for the ill and injured. The drive for change must start “in the trenches,” with emergency physicians serving in the resident or supervising role. Examining institutional policies or developing new ones as part of quality improvement may reveal simple solutions that have a meaningful impact on patient care. While integrated electronic records are a far cry from complete, examining educational feedback mechanisms, working with local EMS leadership, and implementing improved handoff practices may go a long way in improving patient care.

References

  1. Bucher J, Zaidi H. A Brief History of Emergency Medical Services in the United States. EM Resident. 2013;40(3).
  2. “Transfer of Patient Care Between EMS Providers and Receiving Facilities.” ACEP Clinical & Practice Management Policy Statements. October 2013.
  3. Kessler C, et al. An algorithm for transition of care in the emergency department. Acad Emerg Med. 2013;20(6):605-10. doi: 10.1111/acem.12153.
  4. Meisel ZF, Shea JA, Peacock NJ, et al. Optimizing the patient handoff between emergency medical services and the emergency department. Ann Emerg Med. 2015;65(3):310-317.e1.
  5. Dawson DE. National Emergency Medical Services Information System (NEMSIS). Prehosp Emerg Care. 2006;10:314–6.
  6. Seymour CW, Kahn JM, Martin-Gill C, Callaway CW, Angus DC, Yealy DM. Creating an infrastructure for comparative effectiveness research in emergency medical services. Acad Emerg Med. 2014;21(5):599–607.
  7. Newgard CD, Zive D, Malveau S, Leopold R, Worrall W, Sahni R. Developing a statewide emergency medical services database linked to hospital outcomes: a feasibility study. Prehosp Emerg Care. 2011;15(3):303-19.
  8. Choi B, Tsai D, Mcgillivray CG, Amedee C, Sarafin JA, Silver B. Hospital-directed feedback to Emergency Medical Services improves prehospital performance. Stroke. 2014;45(7):2137-40.
Hashim Zaidi, MD

Hashim Zaidi, MD

Resident, Emergency Medicine, Northwestern Memorial Hospital / McGaw Medical Center, Chicago, IL
Joshua Bucher, MD

Joshua Bucher, MD

Resident Physician, Rutgers-RWJMS Emergency Medicine, New Brunswick, NJ
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