On January 11th, I joined the stage with other emergency medicine clinicians for Scott Weingart’s EmCrit Conference, ResuscitateNYC17. It’s a fantastic conference aimed at EM and critical care clinicians in the New York area, though in truth it attracts delegates from all over the place. Scott’s reputation as an educator and blogger is a clear draw for delegates and faculty and this year was no different; Scott and Felipe Teran put on an amazing set of talks on an inspiring day.
I was delighted to be asked to speak from the perspective of the prehospital clinician on topics that are dear to my heart, and also those that are really important for patient care… namely communication and handover.
You probably know by now that the St.Emlyn’s team always tries to back up our talks with a blog post to share the message widely and to allow those who could not attend to share in the learning. However, translating lectures into a blog post is both challenging and gratifying. A challenge because it’s difficult to show the videos and photos that provided the audience with an underlying appreciation of the complexity of prehospital scene calls. Gratifying because it provides the opportunity to share all of the points that I (accidentally) omitted during the lecture.
In a lecture titled, “I’ve had this patient for 8 minutes”, I chronicled an event in which, as a prehospital nurse, my paramedic partner and I had retrieved a patient from the scene, initiated an airway, started lines, administered PRBC’s, given tranexamic acid (TXA), applied a tourniquet, completed an ultrasound, provided sedation and analgesia, all while managing the environmental hazards of the scene. Upon arriving to the resus room, immediately following the report, I was met with this question:
“Did you consider an NG Tube?”
My response to this situation was less than professional. There were expletives and loud voices involved. I’m not proud of that moment, itt was unacceptable. It was just a question, a totally legitimate question. You see, the problem is that I had become accustomed to entering the emergency department poised for an assault and in defense mode. This talk is my attempt to unpick that feeling and to try and make us all understand why it’s bad for clinicians and it’s bad for patients too.
Take a moment to pause and think about that moment when a seriously ill or injured patient is brought into the resus room. Done that? I guess you’ve chosen the perspective of your profession – now stop again and think about it from the other side. Put yourself in the mind of the other side of the patient’s journey and pause. Does it look the same to you?
In truth EDs are stressful places for prehospital clinicians: we often walk into a massive crowd that is all too frequently a sea of annoyed faces and eager hands. I have become accustomed to positioning my body in such a way that I can keep them at bay while I efficiently peel away the straps, leads, lines and tubes that my partner and I strategically placed. This defensive posture is a learned necessity as a result of past erroneous disconnected lines and extubated patients from hasty movement and poor communication. I doubt very much that this is a problem unique to my region of the world. Patient handover was a topic of a St. Emlyn’s podcast last June (part 1 here, part 2 here) , starting an international conversation among disciplines.
Handover (or handoff if you prefer) is clearly a tricky area and it’s therefore surprising to me that whilst we consider, analyze, debate and prepare for proficiency in many aspects of emergency medicine, this area of practice is rarely analysed. We spend significant time in review and analysis of procedures, literature and best practice, even rare procedures and diagnoses, yet there is a singular event, guaranteed daily, in emergency departments all over the world that we almost never discuss. This must change and we can fix it. This blog is about how we do that. It’s not hard and it does not require administrators, 10-point plans or amazing leadership skills. It just takes you and a few other committed people.
Of course I accept that handover does happen already, we are not going to reinvent the wheel. Patients still need to come in and their care must be passed to the hospital team, so let’s not get radical. Rather, let’s think about the Theory of Marginal Gains. You may have met this from the worlds of Cycling, F1 and Olympic sports. Marginal gains are tiny corrections and improvements, made over time that contribute to larger gains. This is the 1% stuff. If implemented, these tiny, simple little adjustments and gestures will change the way handover works.
Appreciation, Atmosphere, Handover
Appreciation goes a long way. Be nice to one another. Our jobs aren’t easy and neither are yours, but when we come into your house (which, if you hadn’t noticed has a massive red cross on the side and sign that says hospital – so where else do you expect us to go?), we aren’t trying to ruin your day. This is our job and our patient is sick and we know that we are all part of wider system that has to work for the patient. Making that happen when we walk in can be a bit intimidating. The trauma bay is typically filled with a dozen people that we don’t know, and who don’t know us. We know that this is your space and your environment and we respect that, but we are all part of the same team. My helicopter based work means that my team takes patients to a variety of hospitals, so make us feel less like intruders and more like welcomed guests. This will go a long way. Be polite, smile, ask, appreciate what we’ve done.
Respect the profession. Paramedics are not ambulance drivers! They are skilled clinicians who work in a challenging environment that is very different to the clean and well-lit emergency department. We have less individual freedom than doctors and are sometimes constrained by a different set of operational guidelines, dictated by States/regions. The regionalisation of services around the world (stroke/trauma/PCI, for example) means that prehospital and retrieval medicine is undeniably a key component in an increasingly complex health care system. There is no better way to learn this lesson than through immersion in that system so that you can see it from the prehospital perspective. If you can, share a shift with your prehospital partners. No matter what stage of training you are at this is well worth your time and energy and I guarantee you will have a new appreciation for what your prehospital colleagues do. I see this in some of my favourite ED doctors who were previously paramedics; they know what it feels like to get the MI patient out of the inevitable wedge he’s slumped into between the toilet and the wall, and then carry all 350 lbs of him down the stairs in an expedient fashion. They know the challenges of balancing analgesia and airway maintenance for the patient in the motor vehicle collision, whose legs are crushed and whose extrication is long. Whenever a doctor rides out with us they are surprised by the non-medical operational roles we have to manage, in addition to patient care; radios, difficult landing zones, being mindful of pedestrians and hazards.
Define your atmosphere by setting the tone. The incredible Chris Hicks (@HumanFact0rz) posted this photo. His department has rules posted about the expectations and atmosphere in their trauma bay. I love this as it defines an atmosphere of calm and professionalism. Rudeness has adverse effects on team relationships and performance1.
— Christopher Hicks (@HumanFact0rz) August 29, 2015
First, the team lead should introduce themselves. “Hello, I’m Dr. So-and-so.” Address the patient if awake (“Can you tell me your name?” – if they can, the airway is patent). “We will wait here until you are ready to move the patient. Tell us how we can help.” This sets the tone and kindly reminds the receiving team of the rules. Smile: it sounds childish and silly but this is a legitimate human interaction. It indicates, “Welcome to my house. Thanks for what you do.”
On to the handover.
Do your institutions have a handoff bundle like ATMIST 2, SBAR3 or IPASS4 for handover to the units or ICU? Many do; in the US, the hospital accrediting bodies have required handoff bundles as an initiative in an effort to decrease the patient care errors that result during handover5–8. If there is an order that you would like information to be provided, then share that with the prehospital teams. Have a visible checklist in your resus room and point us to that. Paramedics LOVE checklists, especially in a high acuity environment where misinformation or omission are most likely to occur.
Please do not touch my patient until I am ready for you to do so. I can not reiterate this enough: please be ready if I need to hand you something, but don’t touch! If you stay out of the way, my partner and I can have the patient moved over in 45 seconds. If you want me to handover before moving the patient onto the trolley then let me know and don’t change your mind from one day to the next or from one team leader to another (Ed – get a system and use it).
Please be quiet. I am not a multitasker and despite what we would like to believe, nor is anyone else. I cannot talk to you and simultaneously do what I need to do. Also, don’t ask me unnecessary questions before my report. Questions like “Where did he come from?” are going to get an aviation heading and distance “92 degrees for 16 nautical miles”. I’m focused. Non clinically essential questions can wait until after transfer.
The research universally agrees that patient handoffs are high risk. If this is the case, why don’t we treat it as such? In critical phases of patient care we ask for silence in the room, for a “time out”, or for a checklist to be verified, yet in the resus room we are prepared to hastily transfer a patient from a stretcher to a bed and begin assessments even before hearing from the transporting team. Eagerness to take over care for the patient has already put the patient at a disadvantage. In this singular event, we have allowed the immediate desire to take action to override the the importance of patient safety.
A few extra seconds of a good handover is a tiny amount of time in the patient
journey, but those seconds may turn out to be the most valuable.
Please listen: an uninterrupted report takes 60 seconds. That is without interruptions, without the defensive protective posture. If a patient is conscious and can articulate their history or symptoms, the handover is relatively brief and simple. Quite the opposite is true, however, if the patient was found unconscious, agitated or at the scene of an an accident. The puzzle is now missing critical pieces; how the patient was found, events surrounding the injury, general impressions and interventions. These bits of information can only be gathered from those eye witnesses to the scene, those who have been present for the initiation of care, those people standing on the other side of the stretcher. If you have questions, we might be able to answer them. We absolutely will try because we care about this patient and want to be part of your team.
Simple concepts, just as I promised. But we are not quite there yet. All of this discussion is lost if we don’t talk about it, train it and teach it! It would be amazing if there was a universal standard for ED patient handover. There isn’t. There are many variations and thus the disconnect. Work with your EMS partners to set a standard. Create the standard that works for your facility and your prehospital teams. Collaboration on this will form positive relationships. If you like receiving your report in a certain order, post a sign in your trauma bay and direct EMS teams to it. Chances are they have practiced their report in their head en route to make sure it is concise and clear. What order do you want things to happen? Do you want the report first then to transfer over to the ED bed, or vice versa? There are pros and cons to both, but you have to decide what works best in your facility and with your crews. Standardise this (keeping in mind that your crews may go to a number of facilities). EMS loves a checklist; we are happy to cognitive offload and never miss a step. Your nurses, respiratory therapists, radiology technicians and admission representatives need to know the system just as well as you do, so there are not interruptions in critical phases. Once a standard is chosen, train, evaluate, adjust and educate. Simulate arrival of a patient, notice the ergonomics of the room, notice the quiet when people are not shouting, notice the details of the report when it is fluid and uninterrupted.
These are little changes, marginal gains, but when you add them up, they make a massive difference to patient care, patient outcomes and professional relationships. So give it a chance, marginal gains; big results.
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