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Communication between the emergency department and EMS providers is grossly overlooked; during initial education, how many practice hand-offs did you do? How many do you make your students do? Are there certain types of calls that still trip you up? All of us like to talk about the sexy skills and procedures like intubation, cardiac arrest management, etc., but no one really wants to talk about the commonplace things like communication. So, we are going to do just that today. This talk hinges around phone/radio and in-person reports to the emergency department.
Identifying the Problem
There is a fantastic article written by the NAEMSP that you can access here. During this article, there were a few staggering statistics:
- Of the sampled hand-offs from EMS to the ED, only 78% included a chief complaint.
- 47% included pertinent findings; i.e. trauma patterns, diagnostic findings, etc.
- 58% provided a description of the scene.
- This is huge from a patient advocacy standpoint; i.e. is the patient going to return to an unsafe situation? Are there inaccuracies with the scene and the patient’s presentation?
The problem with communication goes both ways:
- EMS providers felt rushed during report by ED staff
- ED staff felt rushed from EMS providers trying to clear for another call
- Differences in priorities; i.e. EMS deems patient to be “sick” and ED has already is dealing with “sicker” patients.
- Report is cut short due to another external situation; i.e. cardiac arrest or violent patient in neighboring room.
- Another major reason that the article found was the reported lack of respect given to the medics that were handing over care.
- What are we doing that we can change to fix the image and lack of respect problem?
What can we do on our end to fix the problem?
- Limit unnecessary communications
- EMS lives on their own autonomous island; we can forget exactly what is happening in other parts of the emergency medicine world. Truthfully, we become hyper-focused on our problems, neglecting to take into account that every time we call in or arrive at in the emergency department, a physician/nurse/tech/etc. has to stop what they’re doing to help us.
- Don’t burden others with decisions you should be making yourself. Take the time to educate yourself on issues that you have called in for in the past; anticipate difficult situations that you have not been involved in yet, and accept mentorship from those that have been in them.
- Causing unnecessary questioning leads to decision-fatigue.
- Anticipate the needs of the emergency department
- Routine calls end in routine hand-offs.
- Every time you call in about a chest pain patient, there are a list of things we all rattle off:
- Every time we have a fall victim, there are more routine things we discuss:
- Mechanical v. Medical?
- Anti-coagulation status?
- Anticipate questions before their asked, and paint a picture that doesn’t solicit additional questions.
- Limit the distractions. One of the biggest recommendations from the NAEMSP article was to wait to give your hand-off until everyone was ready, and not during patient movement.
- When you need everyone’s attention, get people’s attention. There’s a significant difference between being overbearing and being authoritative; numerous studies have linked lack of leadership with missed information and poor patient outcomes.
One of the biggest things that we have preached on this show is the use of checklists. Having pre-prepared prompts is huge! It ensures that you don’t miss anything and reminds you if you do. There is nothing wrong with you as a provider if you use a checklist. In fact, one of the biggest takeaways from the article was to create a standardized approach to EMS hand-offs. If this isn’t something that your organization has done or in the process of doing, it is certainly worth thinking about. There are multiple studies that reveal the efficacy of standardized prehospital hand-offs and how they effect patient care. Remember cognitive offloading? Reduced cognitive bandwidth leads to better absorption of information.
We came up with the mnemonic RADIO(S). This is only one of many different formats that you can use.
- R: Reason, Unit, and ETA
- A: Age, Sex, and Chief Complaint
- D: Describe the event that prompted the response.
- I: Interventions and Vital Signs
- O: Outcome of the interventions and trending of the patient.
- S: Special Resources; i.e. security, respiratory support, etc.
The NAEMSP article discussed using the MIST model:
Here’s another fairly popular model:
- Changes in medical errors after implementation of a handoff program
- Optimizing the patient handoff between emergency medical services and the emergency department