By Stacey Kusterbeck
When Emergency Medical Services (EMS) providers hand off patients to EDs, important information often falls through the cracks. “Very little is understood about communication during handoff of patients from EMS to ED clinicians, specifically for pediatric patients,” says Alexandra Cheetham, MD, a pediatric emergency medicine fellow at Cincinnati Children’s.
Cheetham and colleagues wanted to understand what was communicated during EMS handoffs for the sickest pediatric patients.1 The researchers analyzed 156 patient handoffs from EMS to emergency clinicians at a pediatric ED, using video review of the interactions. In 96% of handoffs, chief symptom and mechanism of injury were included. Prehospital interventions were communicated in 73% of handoffs, and physical exam findings were communicated in 85%.
However, vital signs were reported in less than one-third of handoffs. EMS was less likely to report vital signs (including respiratory rate, heart rate, and oxygen saturation) for pediatric trauma patients than for pediatric medical patients. A Glasgow Coma Scale score, an indicator of a patient’s neurologic function, was reported for fewer than 10% of patients. “These objective assessments of a patient’s condition are critical to determining how sick or injured they are,” says Cheetham. “Missing this information could impact patient care.”
For about half of patients, emergency clinicians either interrupted EMS or asked for information that was provided earlier. “This suggests that ED clinicians were not always engaged in active listening during handoff,” Cheetham says.
As the first medical personnel to interact with patients, EMS often know critical information about the scene, interventions that have been performed, and the patient’s clinical trajectory. This information may be important to the ongoing medical evaluation and management of that patient. “ED clinicians should clearly identify themselves as the people receiving the handoff, actively listen to the handoff, and ask the EMS clinicians specific questions when important patient information is missing,” Cheetham advises.
According to Jeffrey Lubin, MD, MPH, “a whole variety of information might not get relayed to the ED during EMS handoff.” Here are some examples:
• EMS may notice a bent steering wheel or shattered windshield at the scene of a motor vehicle accident. Head or chest injuries might go undetected if these observations are not conveyed to the ED.
• EMS may know the patient initially demonstrated hypotension that resolved with EMS treatment. This could indicate severe illness that is overlooked in the ED — if no one knows about the condition.
• EMS may have given steroids to an asthmatic, or diuretics to a patient with heart failure. If no one in the ED realizes these medications were administered, the patient might inadvertently receive a double dose. Between the hectic ED and the urgency for EMS to return to the road, both parties are likely to rush through the report. “Standardized handoffs can help with this process,” offers Lubin, vice chair of research in the department of emergency medicine at Penn State Health Milton S. Hershey Medical Center.2
Lubin and a colleague analyzed 200 patient encounters. They found significant differences in the transfer-of-care form given to the ED by EMS and what was recorded in the patient care report EMS filed later.3
Medications matched in 66% of cases, and chief complaints matched in 72%. In cases with three blood pressure readings, 30% of the third readings were available in the transfer-of-care form vs. 68% in the patient care report. “Initial EMS reports are often incomplete, and may not be consistent with the final electronic report that is provided to the receiving hospital,” Lubin concludes.
To be sure all important information is conveyed during the initial verbal handoff, Lubin recommends using closed-loop communication. For example, EMS might state, “I gave the patient 40 mg of furosemide en route to the hospital.” The receiving nurse responds: “That was 40 mg of furosemide?” The EMS provider confirms, “That’s correct.”
Lubin also recommends using clarifying questions. For example, EMS might state, “I gave the patient 50 micrograms of fentanyl en route to the hospital.” The receiving ED nurse asks: “Is that fifty, five-oh, or fifteen, one-five, micrograms?”
“The use of good communication and error prevention skills is crucial,” Lubin underscores. EDs frequently rely on EMS to clarify why a patient is in the department, what EMS observed at the scene, what treatment was performed, and information about the patient’s initial status. “EMS holds a wealth of information about a very critical time in the patient’s treatment and evaluation for that episode,” says Kendall McKenzie, MD, professor and chair of the department of emergency medicine at the University of Mississippi Medical Center.
In the ED, providers are managing other sick patients. Emergency physicians (EPs) might need to stabilize or intubate another patient who just arrived, or might need to initiate the workup on a patient who arrived by ambulance. “Oftentimes, we have to act before we talk to EMS and get all the information they have. It often leads us to minimize our interaction with EMS,” McKenzie laments.
Sometimes, EMS leaves before the EP can ask for the full story. “That can definitely lead to some gaps in information transfer,” McKenzie notes. “At the end of the day, it really is up to the individual physician, the EMS agencies that you work with, and the hospital as well, to figure out what gaps you see, and try to develop more specific tools to close those gaps.”
Some EDs could gather information from EMS in a certain order. Other institutions might record EMS handoffs, making those part of the medical record.
As far as verbal reports, to a certain extent it falls on the shoulders of the individual EP to ask questions of EMS, especially if EMS does not offer the information freely. “But then, the written record from EMS throws some additional challenges and concerns into the mix,” McKenzie observes.
State law factors into whether EMS must complete reports by a certain time. “If a state says that the report has to be sent within 24 hours, that’s a long time from the patient arrival in the ED to receiving that written report,” McKenzie says. Ideally, EMS would bring the patient in, finalize the report while still in the ED, and give it to emergency care providers, who would carefully review it before entering the information into the medical record. “But as overburdened as the EMS system is right now, we do not have that luxury,” McKenzie says.
EMS providers are dealing with a lack of personnel to work in the ambulances, high patient volumes, diversions, hospital beds shortages, long transport times, and interminable wait times to unload patients. Individual ambulance services want EMS providers to return to service quickly. “All of that strain on the EMS system sometimes does not allow them to complete their documentation while still at the ED,” McKenzie says.
For EDs, McKenzie says the best approach is to work closely with the EMS community, educate individual EMS providers on the standard way the ED wants to conduct handoffs, and stick to it. “When you have a process that you follow and you don’t deviate from it, you probably decrease risk quite a bit,” McKenzie says.
REFERENCES
1. Cheetham A, Frey M, Harun N, et al. A video-based study of emergency medical services handoffs to a pediatric emergency department. J Emerg Med 2023. doi: 10.1016/j.jemermed.2023.04.011.
2. Maddry JK, Simon EM, Reeves LK, et al. Impact of a standardized patient hand-off tool on communication between emergency medical services personnel and emergency department staff. Prehosp Emerg Care 2021;25:530-538.
3. Lubin JS, Shah A. An incomplete medical record: Transfer of care from emergency medical services to the emergency department. Cureus 2022;14:e22446.
EMS holds a wealth of information about a very critical time in the patient’s treatment and evaluation for that episode. Physicians, EMS agencies, and hospital leaders should collaborate to figure out what gaps exist and develop specific tools to close those gaps.
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