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Patient handovers: 10 things you need to know to save lives

What EMS providers need to know and do to avoid serious breakdowns in the continuity of care


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By Rommie L. Duckworth, BS, LP

The American College of Emergency Physicians has called patient handover “the most dangerous point in a patient’s ED journey,” and the World Health Organization has identified communication during patient handover as a critical failure point that can cause “serious breakdowns in the continuity of care, inappropriate treatment and potential harm to the patient.” [1,2]

Effective patient handover practices are as important during routine patient transports as they are for patients receiving emergency transport with a trauma alert.
Effective patient handover practices are as important during routine patient transports as they are for patients receiving emergency transport with a trauma alert.

Every EMS patient will experience at least one, if not several transfers of care before they even reach the hospital, each one a potential point of miscommunication and failed care.

To stay at the top of your patient handover game, here are 10 recommendations that every EMS provider should know. [3,4,5]

1. Learn from other industries

Effective handover processes have been studied by many industries where communications is mission-critical, including commercial aviation, nuclear facilities, the military and fire/rescue organizations. [3,4,5,6] While the exact practices of how to overcome noise, distractions and other challenges will vary from industry to industry, EMS can learn a lot from the practices that other industries have successfully adopted. [5,6,7]

2. Don’t let care compete with communication

Effective patient handover practices are as important during routine patient transports as they are for patients receiving emergency transport with a trauma alert. However, receiving providers are often so focused on the critical care needs of patients that they jump right in without paying attention to communication from the reporting providers. [5]

EMS providers must ensure and assure receiving providers that all lifesaving care will be continued while the reporting team leader gives the receiving team leader an efficient handover report. In some systems this is considered so important that for critical patients, there is a moment of silence during which the reporting team continues care and the entire receiving team focuses on the reporting team leader while the report is given.

3. Share your mental model

“Mental model” is the term for a person’s understanding of what’s going on in the world around them. [7] To provide great patient care, an EMS provider must make sure that they share the same mental model of their patient’s situation with their team.

If team members have a different understanding of what is going on, care won’t be coordinated and serious errors may occur. The priority for both reporting and receiving parties is to develop a shared mental model by answering the following questions:

  1. What is the context (stroke patient, multi-trauma, sepsis, etc.)?
  2. What got us to this point?
  3. Where are we right now?
  4. What is the priority?
  5. What is the very next thing that needs to happen?

4. Prioritize information

Priority information, such as “trauma alert” and “BP 60 over 40,” must be delivered first for the receiving team to develop a mental model and understand the situation. Supplementary information, such as “patient is on metformin” or “patient has had a hysterectomy,” still matters, but the receiving team shouldn’t be bombarded with it up front.

5. Streamline communications

The goal is for the right information to be in front of the right people at the right time, even across multiple patient handovers. Modern communication systems, including prehospital notification software, allow information to be captured early and easily, and efficiently delivered to all key patient care providers along the continuum of care.

For some services, this means acquiring a 12-lead EKG that is automatically sent with key patient information and a cardiac alert to the attending ED physician and interventional cardiologist for evaluation. [8,9] For others, video and audio clips with key information can be captured and securely transmitted from the scene. Still others may pre-register the patient before arrival at the ED, simplifying the entire handover process.

6. Make eye contact

When delivering a face-to-face patient handover report, it’s important for the reporting and receiving team leaders to make direct eye contact. It may seem like multitasking would make things go faster, but an EMS provider trying to give a report while moving a patient over to the hospital bed, or a receiving nurse “listening” while looking up the patient’s hospital medical record, will cause information to be misunderstood or completely missed. [10] Eye contact says, “I am ready to report” and confirms, “I am ready to listen.” [5,10]

7. Control what you can in the environment

While we may not always have as much control over the environment as we would like, it’s important to minimize distractions, interruptions and disruptors of communication. Simply taking a moment to close the door, turn down a radio or move away from a source of noise can make the whole handover process more efficient and less error-prone.

8. Provide a structured report

Many mnemonics exist to provide structure to both the reporting and receiving sides of patient handover. SBAR, AT-MIST, PACE and many more have all been evaluated and adopted by various healthcare institutions without any being proven superior to the others, across all situations [6]. While SBAR may be the most commonly used mnemonic in the United States, whichever one you choose to provide structure and standardization to your reports, ensure that it is understood and used by both reporting and receiving providers so that everyone is speaking the same language. [12,13]

9. Provide supplementary documentation

Supplementary information can be critical to the ongoing care of the patient and should be complete and correct when handed over, but it should never overshadow the key points and priority information delivered upfront in the patient handover. This information can be provided verbally, in written form or electronically delivered.

10. Turn problems into opportunities

Fortunately, great patient handover practices can do more than just help us avoid errors – they also provide the opportunity for a new look at the patient’s condition. The Department of Defense says that patient handovers present not only points of vulnerability, but also potential times to correct errors and gain a fresh clinical perspective [14].

Conclusion

Most EMS systems are already encouraging or mandating several of these recommendations. While few of us can flip a switch and see all 10 instituted immediately, every EMS provider can do their part to help improve patient handover communications.

Remember, your patients are depending on it – not just on the way to the hospital, but at every point along their continuum of care.

References

1. Welch, S. The Handoff. acep.org (2016). Available at: https://www.acep.org/how-we-serve/sections/quality-improvement--patient-safety/key-content/qips-tips2/11---the-handoff/.

2. World Health Organization. Communication during patient hand-overs. 1, (Patient Safety Solutions, 2007).

3. Patterson, E. S., Roth, E. M., Woods, D. D., Chow, R. & Gomes, J. O. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int. J. Qual. Health Care 16, 125–132 (2004).

4. Brindley, P. G. & Reynolds, S. F. Improving verbal communication in critical care medicine. J. Crit. Care 26, 155–159 (2011).

5. Cohen, M. D. & Hilligoss, P. B. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Qual. Saf. Health Care 19, 493–497 (2010).

6. Riesenberg, L. A., Leitzsch, J. & Little, B. W. Systematic Review of Handoff Mnemonics Literature. Am. J. Med. Qual. 24, 196–204 (2009).

7. CommunicationTheory.org. Mental Model. Communication Theory (2013). Available at: http: (Accessed: 11th March 2019)

8. Greene, J. EMS and Information Sharing: Challenges and Innovations in Getting Patient Data From the Ambulance to the Emergency Department and Back. Ann. Emerg. Med. 64, A15–A17 (2014).

9. Dickson, R., Nedelcut, A., Seupaul, R. & Hamzeh, M. STOP STEMI©-A Novel Medical Application to Improve the Coordination of STEMI Care: A Brief Report On Door-to-Balloon Times After Initiating the Application. Crit. Pathw. Cardiol. 13, 85–88 (2014).

10. Laxmisan, A. et al. The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. Int. J. Med. Inf. 76, 801–811 (2007).

11. Accreditation Council for Graduate Medical Education. New ACGME Requirements for Handoffs. (2011).

12. National Health Service. SBAR - Situation - Background - Assessment - Recommendation - NHS Institute for Innovation and Improvement. institute.nhs.uk (2008).

13. Haig, K. M., Sutton, S. & Whittington, J. SBAR: a shared mental model for improving communication between clinicians. Jt. Comm. J. Qual. Patient Saf. Jt. Comm. Resour. 32, 167–175 (2006).

14. Department of Defense. Department Of Defense Patient Safety Program Healthcare Communications Toolkit To Improve Transitions In Care. (2005).

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