One of the benefits for ED doctors involved with HEMS is that is gives us a different perspective on our own speciality by observing it from the outside.
During one recent job, I delivered a moderately unwell trauma patient to a trauma centre. The patient was unwell enough to require pre-hospital radio notification and was met by a team in resus. The hospital in question deals with a lot of trauma, and deals with it well.
On this occasion however, the ED was heaving, and on arrvival I got the impression that the receiving team had been cobbled together at the last minute out of all available resources. Everyone looked busy and stressed. There was not a clearly identified team leader. On our arrival, there was a request to get the patient onto the ED bed immediately, although no immediate intervention was required.
-A flurry of activity – airway, breathing, circulation, nudity (there is always someone running amok with a pair of scissors!)
-A lot of noise but not much effective communication
By this stage I had (sort of) figured out who the de facto team leader was, and delivered a handover. The team leader was distracted repeatedly during the handover by the flurry of information and noise being directed at him by the people performing tasks on the patient.
It stuck me at the time that me giving a handover under those circumstances was pretty ineffectual, and relatively high-risk – it would have been very easy for crucial pre-hospital information to be lost into the ether.
I don’t wish to be too critical of the receiving team – I have no doubt that I have been involved in similar situations on the ED side over the years. Being involved in the handover process from the pre-hospital side however provided a unique insight, and made me think “there must be a better way“.
The literature clearly shows that there are significant issues with handover of clinical information from pre-hospital providers to ED teams. This study found that despite ambulance officers adopting a structured handover format to convey information, at least HALF of the relevant information was NOT retained by the ED team. Another study found that over a quarter of patient records had errors or omissions in transmission from ambulance documentation to ED documentation regarding pre-hospital events and treatment.
Translation: We (the ED team) may have a major listening problem!
The authors of this paper surveyed pre-hospital and ED staff to identify the specific issues with handover, and identified the following problems:
- difficulties in creating a shared cognitive picture
- tensions between ‘doing’ and ‘listening’
- fragmented communication
So how can we do it better?
The following video shows a handover model, including use of a whiteboard, that we (the HEMS Educational Group) believe is highly effective.
The steps involved:
1. Prehospital notification and assembly of team
(including delegation of roles and responsibilities within the team PRIOR to the patient’s arrival)
2. Clear identification of the team leader
The team leader has an important role in generating space/quiet for handover to occur. In the event that pre-hospital staff wish to pass on further information after the initial handover, there must be a clear go-to person who is not task focused, and is therefore in a position to listen to new information.
3. Decision to handover PRIOR to transfer to ED bed
We all know that when the patient hits the ED bed, the ED team can’t help themselves! Unless the patient requires urgent transfer to the ED trolley for immediate intervention (a minority of resus patients), an effective way of ensuring that everyone listens to the handover is to stop the stretcher next to the ED bed and deliver handover PRIOR to transfer. In this way a) everyone listens, and b) everyone has a shared mental model from the outset, before individual task fixation occurs.
The decision about handover prior to transfer versus immediate transfer is best made by the prehospital team.
There are a variety of methods of structured handover. MIST-AMBO is one commonly in use by St Johns staff that provides a concise and relevant summary of pre-hospital information.
5. Use of a whiteboard
Whiteboards are an effective way of ensuring that all team members have access to relevant pre-hospital information.
While in an ideal world all team members would be in resus prior to the arrival of the patient, in practice this does not happen ,and people come and go. For a trauma case in Auckland ED, for example, we routinely have the ED consultant, the ED registrar, the ICU registrar, the general surgical registrar, the trauma fellow, the trauma consultant, the trauma coordinator, and occasionally orthopods and intensivists coming in and out of resus. Use of a whiteboard populated with relevant information is a powerful tool for building a shared mental model without the trauma team leader having to provide the same information to multiple individuals in succession.
A paper discussing the use of whiteboards in improving ED communication can be found here.
Full text pdfs for this post are available here (secure area limited to ADHB staff only – ADHB has subscription access for staff to these journals through the Philson Library at the University of Auckland School Of Medicine)