Information Loss in Trauma Patient Handovers
Carter AJ, Davis KA Evans LV, Cone DC. Information loss in emergency medical services handover of trauma patients. Preh Emerg Care 13(3): 280--85, Jul--Sep 2009.
Abstract: Little is known about how effectively information is transferred from emergency medical services personnel to clinicians in the emergency department receiving the patient. Information about prehospital events and findings can help ensure expedient and appropriate care. The trauma literature describes 16 prehospital data points that affect outcome and therefore should be included in the EMS report when applicable.
Objective: To determine the degree to which information presented in the EMS trauma patient handover is degraded.
Methods: At a level I trauma center, patients meeting criteria for the highest level of trauma team activation ("full trauma") were enrolled. As part of routine performance improvement, the physician leadership of the trauma program watched all available video-recorded full trauma responses, checking off whether the data points appropriate to the case were verbally "transmitted" by the EMS provider. Two EMS physicians then each independently reviewed the trauma team's chart notes for 50% of the sample (and a randomly selected 15% of the charts to assess agreement) and checked off whether the same elements were documented ("received") by the trauma team. The focus was on data elements that were "transmitted" but not "received."
Results: In 96 patient handovers, a total of 473 elements were transmitted, of which 329 were received (69.6%). On the average chart, 72.9% of the transmitted items were received (95% confidence interval, 69.0%--76.8%). The most commonly transmitted data elements were mechanism of injury (94 times), anatomic location of injury (81) and age (67). Prehospital hypotension was received only 10 of the 28 times it was transmitted; prehospital Glasgow Coma Scale score 10 of 22 times; and pulse rate 13 of 49 times.
Conclusions: Even in the controlled setting of a single-patient handover with direct verbal contact between EMS providers and in-hospital clinicians, only 72.9% of key prehospital data points transmitted by the EMS personnel were documented by receiving hospital staff. Elements such as prehospital hypotension, GCS score and other prehospital vital signs were often not recorded. Methods of "transmitting" and "receiving" data in trauma as well as all other patients need further scrutiny.
Comment: Information gaps in emergency medicine are a known challenge, and inaccuracies or incomplete data can negatively affect patient care and safety and increase medicolegal risk. This well-done investigation addresses the "he said/she said" communication breakdowns we often see in the EMS-to-ED transitions. Videotaping the handoffs eliminated questions about who said what and when.
Of the 16 important trauma care elements, information verbalized by EMS became part of the medical record less than 70% of the time. Surprisingly, some of the most essential items, such as hypotension, GCS and pulse rate, were received less than half the time. Although it is possible that the trauma team heard and acted on the information even though it was not recorded, a complete medical record is important for ongoing care, so this is a concern.
How can this be addressed? First, it will require a team approach involving both EMS and hospitals, and everyone needs to understand the importance of accurate and complete information transfer. Second, trauma is just part of the puzzle, as handover information loss likely also applies to other EMS-to-ED patients, especially the critically ill. And third, although this study focused on receipt of transmitted information, the authors also found that fewer than 50% of essential elements were ever verbalized by EMS--a potentially even greater concern.
Possible solutions include an abbreviated documentation using a formatted checklist that can be completed by EMS on delivering the patient, and timely completion and delivery of the run report, either in the ED or electronically. EMS systems should consider evaluating their information transfer and documentation performance as a QI project.
Angelo Salvucci, Jr., MD, FACEP, is an emergency physician and medical director for the Santa Barbara County and Ventura County (CA) EMS agencies.
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