Patient Handover

In our region we have hotly debated the issue of EMS leaving run forms prior to leaving the hospital. We have been debating this for over twenty years. Sure, ideally you deliver the patient, you go to the EMS room, you sit down and write a detailed and thoroughly documented PCR describing everything about the call. Whether the patient is a cardiac arrest or a stubbed toe, each run form is perfect.

Unfortunately, the world is not perfect. EMS run forms are not always done on time, not always turned in and not always complete. Why? The chief reason is the pager on our belts calling “Status Zero” or my service area is 20 minutes away and there is no one in the town covering while we are here at the hospital.

I am in a unique position to view this controversial topic. I am a paramedic who is required to leave the run form. I am an EMS coordinator who, in a way, is the one requiring the run forms be left. And I am the trauma data coordinator, who needs the run forms in order to enter the data into the trauma registry as required by our state regulations (this is actually done after the patient has been discharged from the hospital and if the PCR is not in the medical record, I can get it from the ambulance company).

I am not a black and white guy. My answer on whether or not you must leave a run form depends. I love the “IT depends…” answer because most things do depend. If your patient is unable to answer for themselves, if the patient received a complicated course of care, then by all means, you must complete your form before leaving. If on the other hand, your patient is alert and oriented or who has family with them who can tell the story as well as you can, then go ahead, respond to the “Status Zero” and “Can you clear for a 911?” page, or if your service area is a distance away and no one is covering your town, go ahead and leave, just be sure to fax your PCR when you are done with it.

Once or twice a year, I have the ED staff tell me they need a run form and the crew has left without completing it, but that is rare. One local hospital has a box for EMS to leave their run forms, and I have seen the box filled to the brim. No one has come to get the forms. True, on other days, I have seen the box emptied at a regular interval.

Part of the problem with PCRs now that they have gone electronic is they take much longer to complete than the old paper ones I could write out in five minutes. The new electronic forms are so onerous that I often start the run form on the way to the call, and then after I have done any necessary interventions, I spend most of the ride to the hospital with the computer on my lap, clicking away through all the drop boxes. In the old days, I would hold the patient’s hand and chat about whatever they wanted to talk about. Now, it is just peck, peck, peck on the keyboard. (I type with two fingers – an extremely fast machine gun hunt and peck).

Recognizing both the nature of high-volume EMS these days (fewer ambulance, more calls), and the difficulties with the EPCRs, we have had some discussions about leaving a short hand written form at patient turnover, but we have never gotten far with agreeing on a uniform form, and there are some questions about whether or not it is an official part of the record, etc. I thought the short form was an excellent idea.

As a coordinator, I have noticed an alarming disconnect at times between the EMS PCR and what I read in the ED chart. I noticed discrepancies between drug administrations and narratives.

We decided to measure the discrepancy rate between the EMS PCR and the ED chart by focusing on medications administered prehospitally. The error rate was quite high. We then introduced an intervention – a short handover form that listed the drugs given by EMS. We thought this form would solve the problem, but it didn’t. The error rate continued to be high. The written form was no panacea. To be fair, we had no way of measuring EMS compliance with the form.

We are currently trying to decide what we can do to address the discrepancy problem. If the medications are off, what about the narrative? I can tell you from reading discharge summaries, from some of them is it apparent, they read the ED chart, but not the EMS run form, which tells a different story than the ED chart.

To me, the problem is in the handover. I know some systems have a specially designed SBAR-type method of handing over patient care. Lacking such a method here, too often I notice during handover and verbal report, there are constant interruptions. The flow of the report is disjointed. Sometimes, the nurse doesn’t process what I say, sometimes due to the interruptions, I forget something important, and have to come back later if I remember and say, “Oh, yeah, I forget to tell you, I gave them Zofran.”

I think the only way to solve the turnover issue is to require a formal face to face turnover process following the SBAR method, and insisting on respect between EMS and the ED staff. Again, depending on the patient, a proper verbal turnover should, in most cases, obviate the need for EMS to spend a half an hour writing their run form prior to leaving the hospital and returning to service.*

***

*The productivity cost of EPCRs: Assuming it takes 30 minutes to correctly fill out an EPCR, a paramedic working a 12 hour shift(who does not write the PCR during active patient care), doing 8 calls, will spend 4 hours or 33% of his time sitting in an EMS room out of service. I would rather have the paramedic clear the hospital, and write the run form while traveling to a posting location and fax it in as soon as they are done, than be kept off-line until they are finished. The key of course is being able to carry off an effective verbal turnover.

***

BACKGROUND:
The accuracy of communication between paramedics and ED staff is important for optimal patient safety. Written documentation of prehospital care is frequently delayed making handoff communication especially critical.

OBJECTIVES:
Our main goal was to measure the medication discrepancy rate between the EMS patient care report (PCR) and ED chart. We also sought to test whether introduction of a short handover form would affect the discrepancy rate.

METHODS:
This was a before/after study comparing EMS and ED documentation of medication administration involving a single service of intercept paramedics and the ED where they transport the majority of their patients. The primary intervention was the introduction of a brief medication administration form. The pre and post-intervention periods each comprised 23 weeks. The proportion of discrepancies between the ED record and EMS PCR were compared using chi square analysis. Discrepancies were categorized according to whether (1) medication given prehospital was not listed in the ED record, (2) medication not listed in the EMS PCR was listed in the ED record, and (3) incorrect dose was recorded. Assuming a baseline discrepancy rate of 30%, a sample size of 118 patients per group would provide 80% power to detect a 50% decrease in discrepancy rate with alpha = 0.05. We included an additional 11 patients per group (10%) to account for incomplete data.

RESULTS:
We analyzed 258 record pairs, 129 before and 129 after the introduction of the medication form. Mean patient age was 64.3 +/- 22.3 and 54% were women. Overall, the discrepancy rate was 36.4%. There was no significant difference between the two periods (33.3% vs. 39.5%, p = 0.1329). Medications documented in the PCRs but not ED records accounted for 65 discrepancies (69%), four of which involved controlled substances. Missing or incorrect dose information accounted for 28 (29.8%) instances. In both time periods, nebulized medications (22.3%), ondansetron (20.2%), and aspirin (16%) accounted for most discrepancies.

CONCLUSION:
In this pilot study, the discrepancy rate between EMS PCRs and ED records was substantial. Implementation of a brief medication administration form did not alter the discrepancy rate. Omission of medications listed in EMS PCRs but not in ED records was the most common type of discrepancy.

5 Comments

  • KellyCormier says:

    Peter,

    This is a fight that I, just like yourself and so many others have looked at in my EMS history of 25 years.I’m in a pretty unique situation as a former provider, a wife of a firefighter and someone who works with medic and firefighters across the country. I have developed a different type of documentation class simply because I’ve become passionate about it and its proven quite effective. Do you have a direct email or number where I might be able to reach out to you? I think this study, perspective, debate and information could be a good help to LOTS of personnel and administrators I work with. Best regards,
    Kelly Cormier
    281-740-2232

  • Dan says:

    Make it so I don’t have 6 cords to choose from and the driver for the printer works from HH to JMH to Children’s to RGH and maybe I won’t fax every single runform in. But I have been saying that for years.

  • David says:

    The techie in me dreams there may be a technological solution, with seamless integration of pre-hospital and inpatient charts, live updating, maybe even voice recognition that would be almost like dictation, getting everything in the correct fields in the software … then I wake up, snort and chuckle a little.

    Seriously though, does anyone out there record a simple audio file of verbal hand-offs at the ED? Maybe that’s a start. The computer is right there…record, upload, and that’s at least a starting reference point for both parties. Just a thought.

  • Mark J. Tenerowicz says:

    I am an ED doc and EMS medical director and I expect but don’t demand that my crews leave their run form before clearing. Failure to do so should be the exception, not the rule. I realize services operate in the real world of limited resources and unpredictable calls. If it being done at the station to facilitate dinner, watching the last 3 innings of the Sox game, or to get out on time, that is a no go. Too many times (especially with psychiatric patients, intoxicated patients, seizures, syncope, and the elderly- especially the demented) I find myself asking who called? why? how long? how far? witnessed? etc? Often the verbal hand off documented by the RN in a 3-5 line note has not addressed the questions I need answered to provide the best patient care possible. 2 other points. First, the best consultants in my hospital (cards, ICU, etc) quote DIRECTLY from EMS run forms indicating their importance! Second, any critically ill patient needs their run form handed to the MD or RN at the beside. The EMS assessment, history, physical, VS, EKG, and treatment are too critical not to be incorporated into my critical thinking/decision making at the earliest point possible. Keep up the great work in the field and stay safe.

  • Jon Kavanagh says:

    Handover needs to be handover. The physical transfer of the patient needs to be a separate step. Introduce the nurse/team to the patient, give the relevant stuff, then move the patient over; even in a high acuity patient, unless he is ready to die without an immediate intervention by the physician, the 15-30 seconds spent talking helps to keep problems from coming up later.

    This could work, too, if extra staff are focused on moving the patient, and the Paramedic is speaking directly with the primary nurse/physician/PA, with none of them involved in the physical transfer of care.

    Finally, handover to EMS from the hospital needs to be just as important of a process. None of the “the info is in the packet”…

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Peter Canning

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  • Comments
    BH
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