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)
In a recent study from Toronto, researchers studied paramedics in two similar scenarios. Both scenarios involved a 50 year old patient suffering from chest pain. The patient develops pulmonary edema, hypotension and an ECG reveals a STEMI. All study participants (paramedics) performed interventions based on their established local protocols.
In the “high stress” scenario, there was an actor playing the patient’s partner who was visibly distressed and challenging the paramedic’s actions. Also, all alarms were turned up to full volume and there was constant 2-way radio communication going on in the background. None of this occurred in the “low stress” scenario.
Paramedics were assessed using a global rating scale, a checklist scale and their salivary cortisol levels were measured before and after each scenario (as a response to stress).
The authors noted that “When faced with clinically relevant stressors, paramedics demonstrated signiﬁcant increases in subjective (anxiety) and physiological
(salivary cortisol) measures of stress. These stress responses were accompanied by impairments in some aspects of clinical performance and in the ability to accurately recall information from the case. Although the paramedics demonstrated no impairments in
their ability to complete each individual action required for the particular scenario, decreased scores on the global rating scale indicate that overall they did so more poorly, with less organization and poorer communication or interpersonal skills.”
Overall, paramedics did feel more stressed in the “high stress” scenario – this was measured both by a survey and cortisol levels. And while they were able to complete all relevant tasks, their global performance assessment was reduced as was their ability to recall specific case details.
Fascinating study! We must recognize the high potential for error among clinicians when faced with stress.This data should guide us towards the increasing use of emergency checklists so that things are not forgotten in stressful environments, Such findings will lead nicely into a new video by Scott Orman about the use of whiteboards in handovers and the potential for inaccurate data transmission (unless there’s protocols in place to document better!).
These authors also did a similar study with residents – with similar findings! We need to do better as clinicians & educators in recognizing stress as a huge factor leading to errors and implement interventions to manage these potential threats and errors.
Here’s the abstract
The impact of stress on paramedic performance during simulated critical events.Prehosp Disaster Med. 2012 Aug;27(4):369-74. Epub 2012 Jul 25. Leblanc VR, Regehr C, Tavares W, Scott AK, Macdonald R, King K.
Substantial research demonstrates that the stressors accompanying the profession of paramedicine can lead to mental health concerns. In contrast, little is known about the effects of stress on paramedics’ ability to care for patients during stressful events. In this study, we examined paramedics’ acute stress responses and performance during simulated high-stress scenarios.
Twenty-two advanced care paramedics participated in simulated low-stress and high-stress clinical scenarios. The paramedics provided salivary cortisol samples and completed an anxiety questionnaire at baseline and following each scenario. Clinical performance was videotaped and scored on a checklist of specific actions and a global rating of performance. The paramedics also completed patient care documentation following each scenario.
The paramedics demonstrated greater increases in anxiety (P < .05) and salivary cortisol levels (P < .05) in response to the high-stressscenario compared to the low-stress scenario. Global rating scores were significantly lower in the high-stress scenario than in the low-stress scenario (P < .05). Checklist scores were not significantly different between the two scenarios (P = .12). There were more errors of commission (reporting information not present in the scenario) in the patient care documentation following the high-stress scenario than following the low-stress scenario (P < .05). In contrast, there were no differences in omission errors (failing to recall information present in the scenario) between the two scenarios (P = .34).
Clinical performance and documentation appear vulnerable to the impact of acute stress. This highlights the importance of developing systems and training interventions aimed at supporting and preparing emergency workers who face acute stressors as part of their every day work responsibilities.
Full text pdf is 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)