Transitioning Care at the Hospital

      When EMS arrives at the hospital and care of the patient is transferred from paramedics to the nursing staff or trauma team, the staff can always tell the seasoned paramedic crews from those still learning the ropes. One crew arrives with patient treatment underway, a report prepared and anticipating what the nurses are going to ask, and can follow the routine without instruction. Another crew arrives with the patient unprepared, gives a disjointed report and has to be asked by the nurses to assist in boosting the patient to the trauma stretcher. Can you tell which crew is which? The hospital staff, especially front-line nursing staff, are always appreciative when the EMS crew patches a call in correctly, arrives prepared and assists with the little details with the noncritical patients. The patient is at a critical junction in time from their initial injury to their path to recovery, and the time where EMS hands the patient over to hospital staff can be filled with pitfalls that can adversely affect the patient's care. If paramedics take an organized approach when transferring the patient to nursing staff, they can ensure the quality and continuity of care and improve the chances of a favorable outcome for the patient.

   The initial patch call should be short, giving only the most pertinent information. Rather than holding the nurse on the patch phone to give an overly detailed report, patch in early to allow the hospital staff to arrange a bed, call the respiratory therapist, page x-ray, set up the rapid infuser, get the warming blanket out of the storeroom and do all those other tasks to prepare for your arrival. The patch should be problem- focused, with the most life-threatening injury topping the list. If the patient has sustained an arterial bleed, be sure to mention it, since that means the hospital may have to find the vascular surgeon who is on call. Attempting to list the patient's medications only takes time away from the nurse's other duties. Although a brief biography can be helpful, don't get bogged down in irrelevant details. Telling the nurse the 12-year-old with a leg fracture from skiing had his tonsils out five years ago is too detailed for the patch call. A full, detailed report can be given upon arrival. The following case scenarios illustrate these points.

Case #1

   This summer, as I was talking with a crew in the EMS entryway while on my way to lunch, an ambulance showed up under the canopy with full lights and sirens. The crew quickly unloaded a preteen with absent vital signs, undergoing full CPR. The child had fallen into the water at one of the local summer camps and had been down almost 20 minutes at this point. The EMS crew had not patched in, and the ED staff was caught totally by surprise. They didn't even have a trauma room free. As you can imagine, bedlam ensued.

   Learning Point: Patching in with a quick report saves time and allows the ED to prepare.

   Once EMS arrives and rolls the patient into the trauma room, remember the mantra, "To finish sooner, take your time." Allow the nurse to grab a pen and scratch pad/trauma sheet for taking notes. If a report is delivered too quickly to a nurse who is half listening because she's doing several other jobs at once, the report will have to be repeated (often several times), which can waste time and energy. The transition flow is much smoother when one paramedic is assigned to give the report, speaking directly with the nurse or trauma team leader. Nothing adds more to chaos in the room than when two paramedics each give half a report to two different nurses, potentially missing vital information ("I thought you told them." "No, I thought you did.") It is important for paramedics to detail to the nursing staff which treatments the patient has received already to avoid overdosing. Nursing staff also need to know about the patient's allergies, especially if the patient is unable or cannot be trusted to answer questions appropriately. It is also vital to the hospital staff that the paramedic admits he/she does not know certain information. Embellishment or deflection of missed information can be detrimental to patients' health and the care they will receive. Hospital staff must know exactly what has or has not taken place so actions or activities are not duplicated or missed. Having patience with the nurse or team leader who is taking the report is a requirement for quality transition of care. They were not on the scene, so additional questions often have to be asked to ascertain the total picture. Wait until the nurse has the general picture, and then allow her to ask more detailed questions. Basic communication is the key to an excellent report. Save humor for shift break and don't play the 'who's smarter' game. Speak in a normal, moderate tone. The trauma room can be a chaotic, noisy environment, so taking steps to reduce the volume allows the respiratory therapist to auscultate the chest, the physician to hear overhead pages, etc. Nothing adds to the confusion and noise level like an overanxious, adrenaline-pumped paramedic yelling a report to no one in particular in an already noisy department.

Case #2

   One case that sticks in my mind was a violent, self-inflicted stab wound to the chest. The patient came in assisted by another crew (four paramedics), and two firefighters were doing CPR and pulling the stretcher. The nursing staff arrived and began putting the patient on the cardiac monitor. The RT and MD arrived shortly after, making a total of four hospital staff. The paramedic supervisor arrived and wanted to know why the four other paramedics were all needed. Meanwhile, two paramedics were talking to two different nurses. The fire supervisor showed up (three firefighters now) and just basically wanted to check out the patient. Four policemen arrived—two uniformed officers and two detectives—and wanted to interview anyone who had so far talked to the patient. There were now 16 people in a small trauma room with one patient before the thoracic surgeon even arrived.

   Learning Point: Having no more people in the room than necessary means reduced confusion, less noise and patient-focused care. A quick report spoken directly to the team leader allows the team to focus and clears out a room. Once the crisis is over, the hospital staff can update paramedics/police/fire if needed. In fact, nurses always notify the paramedics who check on patients later or after their shifts to see how their interventions turned out and if there was something to learn for next time.

   All EMS crews have arrived at an ED with a noncritical patient and experienced an off-load delay. There are many factors leading to backed-up ambulance stretchers in the halls, some of which cannot be helped. There is a direct correlation between the numbers of ambulance stretchers in the hall and the triage nurse's stress level. The EMS crew that is calm, collected, accepts a wait in good grace and attends to the patient is like gold to a frazzled triage nurse. The crew that arrives and begins to berate the nursing staff for not finding a bed quickly enough, or takes the off-load delay as a personal affront, adds to an already stressful environment for the hospital staff. EMS often does not realize that a large proportion of sick people get themselves to the hospital and arrive at the triage window far sicker than those on the EMS stretcher. Nursing staff are very appreciative when the crew keeps up on charting the patient's vitals, continues to gather patient information, and finds the accompanying family member a chair.

Conclusion

   Because paramedics and ED nurses work hand in hand on a daily basis, having a greater understanding of the nursing staff's duties and what to expect at the hospital leads to greater patient safety and enhanced care. Transitional time can lead to a great deal of stress for both paramedics and nurses, so focusing on smooth continuity of care can allow each member of the team to relax and prioritize on what is most important—the patient's recovery.

   Martin Robbins, BAS, RN, is currently on staff at the Greater Niagara General Site of the Niagara Health System's emergency department. Contact him at martin.robbins@niagarahealth.on.ca.