“But … It Was In My Hand-off Report“
Every EMS responder who delivers patients to the emergency room has experienced the frustration of feeling like the ED staff didn’t really get the whole picture. You came in, you told the story and you said your goodbyes, but somewhere along the way it felt like there was a disconnect.
Now, some excellent research out of Harvard tells us exactly how much of the EMS hand-off report is really making it into the patients chart and being used in the clinical decision making and care of the patient. I’m sure the study findings are going to have a bit of a “duh” effect on responders who give routine hand-off reports to ER staff, but it is nice to feel that your impressions have been validated by some objective measure.
Researchers decided on 16 prehospital data points that were considered to be significant in effecting patient outcomes in level one trauma activations. Then they had a panel of trauma physicians watch videos of the EMT-to-trauma-team hand-off reports and checked off when the data points were actually communicated in the verbal hand-off report. Next they checked the patients medical record to see how many of these data points had been recorded in the patients chart.
A full thirty percent of the data points were never recorded in the medical record. That’s not thirty percent of all the information relayed, that’s thirty percent of the critical data points. Even more telling was the analysis of what information was reliably received and what got left out.
The three data elements that were received most reliably were mechanism of injury, location of wound and patient age. The three elements most commonly left out? Prehospital hypotension was received and documented around 30% of the times it was communicated. The Glasgow Coma Score was documented less than half of the times it was communicated and, this one might surprise you, the pulse rate was only documented 13 of the 49 times it was communicated.
This isn’t about beating up on the ER staff. We have some culpability here as well. There are two sides to every communication and, for our part, we need to make sure the right info is getting across. Here are a few things you can do to insure that the story you’re telling is being received.
1.) Look at the person who is charting while you give the report. Don’t just stare at the doctor. You’re communicating with the whole room, including the nurse with the pen in his / her hand. Watch when they are writing. If you say something important and their pen doesn’t move, say it again. If they are scribbling furiously, slow down. If they get interupted, try to pause until they’re ready.
2.) If there’s something really important to be said, say it first. Notice what stuff got recorded most often. It’s all the stuff we tend to say right at the very beginning. If you want it written down and acted on, say it right at the start.
Hey Doc. Hi Jen, this is Bob and I’m concerned about his ST elevation in 2,3 and AVF. Bob’s 67 years old and he started having chest pain today while mowing his lawn …” If there’s one real doozy of a clinical finding, don’t wait to reveal it till the end of the report. Nurses don’t like suspense. They want to put down the chart and start doing stuff. If you’re trying to build up to a big finish (Wait for it … wait for it ….) your important info is going to get missed.
3.) Do a quick consult with the charting nurse as soon as you finish the report. Once you think your hand-off is done, walk over and ask, “Is there anything I left out?” This not only gives the nurse a chance to re-ask about anything that might have been missed, it’s also great feedback for improving future hand-off reports. I also find that once I’ve put the blame on myself (anything I missed) I can also ask the follow up, “Did you get those vitals I rattled off?” Without sounding accusatory.
Hand-off reports, like all communication, are two way interactions. If you rattle off a quick, impersonal or excessively formal report and then leave the room without engaging the ER staff in the conversation, you can’t assume that all the vital information has been properly received. Your assessments, findings and treatments are important enough to be received and acted upon. You owe it to yourself and your patient to take the time to make sure it all gets received.