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Information transfer from prehospital to ED health care providers
American Journal of Emergency Medicine (2008) 26, 233–244
www.elsevier.com/locate/ajem
Correspondence
Information transfer from prehospital to ED health care providers
To the Editor, The integration of emergency medical services (EMS) with other health care providers, particularly emergency department (ED)–based personnel, has been identified as an area deserving of attention and improvement [1]. The enhancement of communication, particularly at patient transfer, between EMS and the ED health care team is certainly a first step to such integration. We write to you with the results of an ED-based study that we performed involving both qualitative and quantitative analysis of patient-specific data relayed to the ED staff by EMS at the time of patient transfer of care in the ED. The goals of the study were to evaluate the adequacy and to determine the level of physician satisfaction of patient data reported by EMS. Our interest was in evaluating the general process and effectiveness of information transfer to examine communication between both parties within our institution's ED. Emergency Medical Services providers are positioned to gather information of potential importance to patient care in the ED [2]. Prehospital providers have the opportunity to observe patients in unique environments to which ED-based providers do not have access. In many cases, the physician can elicit most relevant information necessary during their examination of the patient. However, in other cases, patients are unable, or unwilling, to share certain components of their history. Hence, specific details relating to a patient's illness or injury may never become apparent in the ED (eg, patients' living conditions, their exposure to violence or other environmental factors, the mechanism of their injury). In many trauma situations, the paramedic's report is often the only source of information about the incident scene available to the physician [3]. In some situations, these details are of great importance in reaching an accurate diagnosis. Concurrently, as EMS providers become involved in the delivery of more advanced care, information regarding such care must be relayed to ED staff with accuracy and completeness. Consider, for example, the establishment of EMS protocols involving the implementation of rapid sequence intubation in 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
the prehospital setting. Considered one of the most important prehospital interventions, endotracheal intubation must include accurate documentation and a thorough verbal report to the ED physician [4]. The details of this intervention are vitally important to the patient's medical record and potentially to their outcome. To accurately study this subject, we conducted an internet survey of both hospital and society-based nurse and physician contacts to generate a list of the most desired case-specific information relating to 7 common ED patient presentations (eg, cardiac history in a patient with chest pain, history of seizures in a patient with seizures). We used the 209 returned surveys to design data forms outlining the 15 most important data points that were most relevant to a patient's injury/illness related to each of the 7 case groups. During the study period, when a patient would arrive to the ED via EMS, who fit any of these case groups, the investigator would compare the patient-specific information reported by the EMS providers to the data points listed on the data form. The investigator would then query the treating physician as to whether they were satisfied with the quality and quantity of information transferred and whether it aided in assessing the patient and/or establishing a diagnosis. We found that EMS transferred 1947 (44%) pertinent data points out of the total points (n = 4425) possible during 296 observed patient transfers in the ED during our study period. Of the 7 case groups, the one with the most relevance for prehospital providers to report unique scene-specific facts was the motor vehicle accident category (see Fig. 1). Here, EMS reported 44% of the pertinent information. The most commonly reported facts were the type of accident (ie, headon) (94%) and the locations of obvious trauma on the patient (91%). The least commonly reported items were whether the patient was entrapped in the vehicle (9%), and if so, the duration of entrapment (3%). The physicians were satisfied with 60% of the reports and dissatisfied with 8%. During this study, we were limited by several factors, most pertaining to the study design. The overall transfer rate of information from EMS (44%) was low, and in some cases, inadequate. There were individual variances in every case that caused information reporting to vary. The reasons for this were examined from both a study-specific and an EMS agency perspective.
234
Correspondence
Fig. 1
The total data transferred by EMS to ED personnel in the motor vehicle crash scenario.
From the study-specific perspective, the design of the study contributed to several limitations. First, the data collection process may not have needed a specific number of data points for each scenario; 6 or 8 might have been sufficient in some cases where more may have been needed in others. For example, an EMS report regarding a minor injury, low speed motor vehicle accident, would not have included information regarding the time a patient was entrapped or whether any other occupants of the vehicle died in the collision. Because the information transfer statistics are based on the number of data points transferred out of 15, any point not reported, whether relevant to the case or not, added to the decline in data-specific communication. In addition, this study design did not account for the specific information that, in most cases, would not have needed to be transferred orally, such as an alert patient's level of consciousness or chief complaint when the physician/nurse is able to determine that by simple observation and questioning as a part of their examination. The variances related to the EMS agency were based on two aspects: the practice level of each different EMS provider and the diversity of the differing agencies. The setting of this study was an academic ED located in a suburban area surrounded predominantly by rural counties. Both career and volunteer EMS providers transporting patients to our ED represent a broad spectrum of training and skill, from rural first responders to hospital-based paramedics with additional training in critical care. Where career services are paid and often have regular continuing education and place a large emphasis on training, many of the volunteer departments do not. Concurrently, it is common for lesser-experienced basic life support providers, who make up most of the personnel in the volunteer departments in this area, to not engage in the level of training compared with that of advanced life support providers [5]. Therefore, the basic life support providers might not be aware of all the important patient information to be gathered on scene that may be helpful for the physicians. The combination of little experience and differences in skill level and training might provide an explanation with respect to the focus of information acquisition and reporting by EMS. In addition,
some providers may not have followed a systematic approach to information acquisition and transfer. One caveat to our findings is that despite the fact that 56% of the data points were not reported at all, the physicians showed a 51% satisfaction rate among the total cases (see Fig. 2). Unfortunately, statistical analysis showed no correlation between the information from EMS crews and physician satisfaction. Often, physicians were satisfied with reports they never even heard. In other cases, if the EMS report was given to a nurse, there may have been a breakdown in the communication from nurse to physician, who may have been satisfied, dissatisfied, or had no opinion regarding the EMS report. Another limitation related to this is that the “physicians” taking the reports included a wide spectrum from first year emergency medicine and off-service residents all the way to emergency medicine attendings. This educational gap may have resulted in varying expectations with regard to information transfer from EMS. In retrospect, improvements certainly need to be made in our current system until we can adequately reform our study.
Fig. 2 The total physician satisfaction in all scenarios transferred to ED personnel.
Correspondence
235
On a system level, increased education early in the national Emergency Medical Technician curriculum on this subject combined with frequent interaction with ED staff could enhance a new provider's method of gathering a detailed patient history. Examples of such improvement on a provider level include making complete oral reports and legible EMS patient care documentation available in each case. This would ensure more effective communication between EMS and nurses, and nurses and physicians. Perhaps having EMS providers report directly to physicians in every case may prevent any communication breakdown occurring in the ED. In addition, efficient delivery of information contained in the EMS prearrival radio reports to the physicians working in the patient care area of the ED would also allow for prenotification of the staff and better organization and use of resources [6]. On final analysis of the EMS transfer and physician satisfaction data, the end points which the study set out to measure were not fully met. The purpose of collecting the data was to determine whether physicians are satisfied with the information they receive from the prehospital environment with respect to their (the physician's) needs and the further treatment of the patient. Taking into account the limitations of this study and the methods of data collection, it appears that further work will be necessary to draw any definitive conclusions about overall physician satisfaction. Future projects might focus on defining physician expectations, needs, and uses of prehospital information before data collection while incorporating a more specific questionnaire to address the issue. Conclusions from this type of study could possibly lead to further refinement of the information transfer process by identifying those pieces of information that are not only important but are also useful to the ED health care team. John P. Benner NREMT-P Josh Hilton MD, CCEMT-P Gordon Carr MD Kimberly Robbins MD Korin Hudson MD, NREMT-P William Brady MD Charlottesville-Albemarle Rescue Squad Charlottesville, VA 22911, USA Department of Emergency Medicine University of Virginia Charlottesville, VA 22911, USA E-mail address: [email protected] Robert C. Schutt MCS, NREMT-P Matthew P. Borloz EMT-I Kostas Alibertis CCEMT-P Benjamin Sojka NREMT-P Dayton Haugh JD, NREMT-P Charlottesville-Albemarle Rescue Squad Charlottesville, VA 22911, USA doi:10.1016/j.ajem.2007.04.003
References [1] Delbridge TR, Bailey B, Chew Jr JL, et al. EMS agenda for the future: where we are…where we want to be. EMS Agenda for the Future Steering Committee. Ann Emerg Med 1998;31(2):251-63. [2] O'Connor RE, Cone DC, De Lorenzo RA, et al. EMS systems: foundations for the future. Acad Emerg Med 1999;6:46-53. [3] Scott LA, Brice JA, Baker CC, et al. An analysis of paramedic verbal reports to physicians in the emergency department trauma room. Prehosp Emerg Care 2003;7(2):247-51. [4] Wang HE, Domeier RM, Kupas DF, et al. Recommended guidelines for uniform reporting of data from out-of-hospital airway management: position statement of the national association of EMS physicians. Prehosp Emerg Care 2004;8(1):58-72. [5] Lilja GP. Emergency medical services. In: Tintinalli JR, Krome RL, Ruiz E, editors. Emergency medicine, a comprehensive study guide. 6th ed. New York: McGraw-Hill; 2004. p. 4-5. [6] Blackwell T. Principles of EMS services. In: Marx J, Hockberger R, Walls R, editors. Rosen's emergency medicine, concepts and clinical practice, 5th ed., vol. 3. St.Louis: Mosby; 2002. p. 2619.
Cardiac troponin and risk stratification in pulmonary embolism To the Editor, We read with great interest the article by Aksay et al [1]. To our knowledge, this is the first study performed in an emergency department (ED) that suggested that cardiac troponin I (cTnI) could predict in-hospital complicated pulmonary embolism (PE). It is interesting because echocardiography is rarely available in most EDs. However, we have several concerns and comments about the method they used and their conclusions. First, it was a retrospective study (with all the methodological biases [2]) of patients admitted with a diagnosis of PE in the ED; we suggest that some PEs could have been missed in the ED and diagnosed later in the ward but not included in their study. Secondly, the prevalence of PE with elevated cTnI and complicated PE was surprisingly high for an emergency setting. In our prospective study of 60 PEs diagnosed in our ED, the prevalence of PE with elevated cTnI was much lower (17% and 8%, respectively, compared with 42% and 39% in their report) [3]. Furthermore, 45% patients in the group with elevated cTnI had hypotension/ hemodynamic stability at admission! We believe that we do not need any biomarkers (even the echocardiographic findings) to assess that these patients with a proven PE and shock have very severe conditions and need close monitoring or thrombolysis [4]. Unfortunately, they reported only predictive values of cTnI, which depend on prevalence of the disease (elevated cTnI and complicated PE in that case) [2], conversely to sensitivity, specificity, and likelihood ratios [2]. We believe that emergency physicians commonly manage many noncomplicated (ie, segmental or smaller) PEs in an ED and that the prevalence of complicated PE is usually lower. We also noticed that the measurement of cTnI was not blind to the emergency physician nor to the cardiac technician/physician, introducing biases [2]. Furthermore, their criteria for thrombolysis in the institution are not detailed. It seems that right ventricular (RV) dysfunction
www.elsevier.com/locate/ajem
Correspondence
Information transfer from prehospital to ED health care providers
To the Editor, The integration of emergency medical services (EMS) with other health care providers, particularly emergency department (ED)–based personnel, has been identified as an area deserving of attention and improvement [1]. The enhancement of communication, particularly at patient transfer, between EMS and the ED health care team is certainly a first step to such integration. We write to you with the results of an ED-based study that we performed involving both qualitative and quantitative analysis of patient-specific data relayed to the ED staff by EMS at the time of patient transfer of care in the ED. The goals of the study were to evaluate the adequacy and to determine the level of physician satisfaction of patient data reported by EMS. Our interest was in evaluating the general process and effectiveness of information transfer to examine communication between both parties within our institution's ED. Emergency Medical Services providers are positioned to gather information of potential importance to patient care in the ED [2]. Prehospital providers have the opportunity to observe patients in unique environments to which ED-based providers do not have access. In many cases, the physician can elicit most relevant information necessary during their examination of the patient. However, in other cases, patients are unable, or unwilling, to share certain components of their history. Hence, specific details relating to a patient's illness or injury may never become apparent in the ED (eg, patients' living conditions, their exposure to violence or other environmental factors, the mechanism of their injury). In many trauma situations, the paramedic's report is often the only source of information about the incident scene available to the physician [3]. In some situations, these details are of great importance in reaching an accurate diagnosis. Concurrently, as EMS providers become involved in the delivery of more advanced care, information regarding such care must be relayed to ED staff with accuracy and completeness. Consider, for example, the establishment of EMS protocols involving the implementation of rapid sequence intubation in 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
the prehospital setting. Considered one of the most important prehospital interventions, endotracheal intubation must include accurate documentation and a thorough verbal report to the ED physician [4]. The details of this intervention are vitally important to the patient's medical record and potentially to their outcome. To accurately study this subject, we conducted an internet survey of both hospital and society-based nurse and physician contacts to generate a list of the most desired case-specific information relating to 7 common ED patient presentations (eg, cardiac history in a patient with chest pain, history of seizures in a patient with seizures). We used the 209 returned surveys to design data forms outlining the 15 most important data points that were most relevant to a patient's injury/illness related to each of the 7 case groups. During the study period, when a patient would arrive to the ED via EMS, who fit any of these case groups, the investigator would compare the patient-specific information reported by the EMS providers to the data points listed on the data form. The investigator would then query the treating physician as to whether they were satisfied with the quality and quantity of information transferred and whether it aided in assessing the patient and/or establishing a diagnosis. We found that EMS transferred 1947 (44%) pertinent data points out of the total points (n = 4425) possible during 296 observed patient transfers in the ED during our study period. Of the 7 case groups, the one with the most relevance for prehospital providers to report unique scene-specific facts was the motor vehicle accident category (see Fig. 1). Here, EMS reported 44% of the pertinent information. The most commonly reported facts were the type of accident (ie, headon) (94%) and the locations of obvious trauma on the patient (91%). The least commonly reported items were whether the patient was entrapped in the vehicle (9%), and if so, the duration of entrapment (3%). The physicians were satisfied with 60% of the reports and dissatisfied with 8%. During this study, we were limited by several factors, most pertaining to the study design. The overall transfer rate of information from EMS (44%) was low, and in some cases, inadequate. There were individual variances in every case that caused information reporting to vary. The reasons for this were examined from both a study-specific and an EMS agency perspective.
234
Correspondence
Fig. 1
The total data transferred by EMS to ED personnel in the motor vehicle crash scenario.
From the study-specific perspective, the design of the study contributed to several limitations. First, the data collection process may not have needed a specific number of data points for each scenario; 6 or 8 might have been sufficient in some cases where more may have been needed in others. For example, an EMS report regarding a minor injury, low speed motor vehicle accident, would not have included information regarding the time a patient was entrapped or whether any other occupants of the vehicle died in the collision. Because the information transfer statistics are based on the number of data points transferred out of 15, any point not reported, whether relevant to the case or not, added to the decline in data-specific communication. In addition, this study design did not account for the specific information that, in most cases, would not have needed to be transferred orally, such as an alert patient's level of consciousness or chief complaint when the physician/nurse is able to determine that by simple observation and questioning as a part of their examination. The variances related to the EMS agency were based on two aspects: the practice level of each different EMS provider and the diversity of the differing agencies. The setting of this study was an academic ED located in a suburban area surrounded predominantly by rural counties. Both career and volunteer EMS providers transporting patients to our ED represent a broad spectrum of training and skill, from rural first responders to hospital-based paramedics with additional training in critical care. Where career services are paid and often have regular continuing education and place a large emphasis on training, many of the volunteer departments do not. Concurrently, it is common for lesser-experienced basic life support providers, who make up most of the personnel in the volunteer departments in this area, to not engage in the level of training compared with that of advanced life support providers [5]. Therefore, the basic life support providers might not be aware of all the important patient information to be gathered on scene that may be helpful for the physicians. The combination of little experience and differences in skill level and training might provide an explanation with respect to the focus of information acquisition and reporting by EMS. In addition,
some providers may not have followed a systematic approach to information acquisition and transfer. One caveat to our findings is that despite the fact that 56% of the data points were not reported at all, the physicians showed a 51% satisfaction rate among the total cases (see Fig. 2). Unfortunately, statistical analysis showed no correlation between the information from EMS crews and physician satisfaction. Often, physicians were satisfied with reports they never even heard. In other cases, if the EMS report was given to a nurse, there may have been a breakdown in the communication from nurse to physician, who may have been satisfied, dissatisfied, or had no opinion regarding the EMS report. Another limitation related to this is that the “physicians” taking the reports included a wide spectrum from first year emergency medicine and off-service residents all the way to emergency medicine attendings. This educational gap may have resulted in varying expectations with regard to information transfer from EMS. In retrospect, improvements certainly need to be made in our current system until we can adequately reform our study.
Fig. 2 The total physician satisfaction in all scenarios transferred to ED personnel.
Correspondence
235
On a system level, increased education early in the national Emergency Medical Technician curriculum on this subject combined with frequent interaction with ED staff could enhance a new provider's method of gathering a detailed patient history. Examples of such improvement on a provider level include making complete oral reports and legible EMS patient care documentation available in each case. This would ensure more effective communication between EMS and nurses, and nurses and physicians. Perhaps having EMS providers report directly to physicians in every case may prevent any communication breakdown occurring in the ED. In addition, efficient delivery of information contained in the EMS prearrival radio reports to the physicians working in the patient care area of the ED would also allow for prenotification of the staff and better organization and use of resources [6]. On final analysis of the EMS transfer and physician satisfaction data, the end points which the study set out to measure were not fully met. The purpose of collecting the data was to determine whether physicians are satisfied with the information they receive from the prehospital environment with respect to their (the physician's) needs and the further treatment of the patient. Taking into account the limitations of this study and the methods of data collection, it appears that further work will be necessary to draw any definitive conclusions about overall physician satisfaction. Future projects might focus on defining physician expectations, needs, and uses of prehospital information before data collection while incorporating a more specific questionnaire to address the issue. Conclusions from this type of study could possibly lead to further refinement of the information transfer process by identifying those pieces of information that are not only important but are also useful to the ED health care team. John P. Benner NREMT-P Josh Hilton MD, CCEMT-P Gordon Carr MD Kimberly Robbins MD Korin Hudson MD, NREMT-P William Brady MD Charlottesville-Albemarle Rescue Squad Charlottesville, VA 22911, USA Department of Emergency Medicine University of Virginia Charlottesville, VA 22911, USA E-mail address: [email protected] Robert C. Schutt MCS, NREMT-P Matthew P. Borloz EMT-I Kostas Alibertis CCEMT-P Benjamin Sojka NREMT-P Dayton Haugh JD, NREMT-P Charlottesville-Albemarle Rescue Squad Charlottesville, VA 22911, USA doi:10.1016/j.ajem.2007.04.003
References [1] Delbridge TR, Bailey B, Chew Jr JL, et al. EMS agenda for the future: where we are…where we want to be. EMS Agenda for the Future Steering Committee. Ann Emerg Med 1998;31(2):251-63. [2] O'Connor RE, Cone DC, De Lorenzo RA, et al. EMS systems: foundations for the future. Acad Emerg Med 1999;6:46-53. [3] Scott LA, Brice JA, Baker CC, et al. An analysis of paramedic verbal reports to physicians in the emergency department trauma room. Prehosp Emerg Care 2003;7(2):247-51. [4] Wang HE, Domeier RM, Kupas DF, et al. Recommended guidelines for uniform reporting of data from out-of-hospital airway management: position statement of the national association of EMS physicians. Prehosp Emerg Care 2004;8(1):58-72. [5] Lilja GP. Emergency medical services. In: Tintinalli JR, Krome RL, Ruiz E, editors. Emergency medicine, a comprehensive study guide. 6th ed. New York: McGraw-Hill; 2004. p. 4-5. [6] Blackwell T. Principles of EMS services. In: Marx J, Hockberger R, Walls R, editors. Rosen's emergency medicine, concepts and clinical practice, 5th ed., vol. 3. St.Louis: Mosby; 2002. p. 2619.
Cardiac troponin and risk stratification in pulmonary embolism To the Editor, We read with great interest the article by Aksay et al [1]. To our knowledge, this is the first study performed in an emergency department (ED) that suggested that cardiac troponin I (cTnI) could predict in-hospital complicated pulmonary embolism (PE). It is interesting because echocardiography is rarely available in most EDs. However, we have several concerns and comments about the method they used and their conclusions. First, it was a retrospective study (with all the methodological biases [2]) of patients admitted with a diagnosis of PE in the ED; we suggest that some PEs could have been missed in the ED and diagnosed later in the ward but not included in their study. Secondly, the prevalence of PE with elevated cTnI and complicated PE was surprisingly high for an emergency setting. In our prospective study of 60 PEs diagnosed in our ED, the prevalence of PE with elevated cTnI was much lower (17% and 8%, respectively, compared with 42% and 39% in their report) [3]. Furthermore, 45% patients in the group with elevated cTnI had hypotension/ hemodynamic stability at admission! We believe that we do not need any biomarkers (even the echocardiographic findings) to assess that these patients with a proven PE and shock have very severe conditions and need close monitoring or thrombolysis [4]. Unfortunately, they reported only predictive values of cTnI, which depend on prevalence of the disease (elevated cTnI and complicated PE in that case) [2], conversely to sensitivity, specificity, and likelihood ratios [2]. We believe that emergency physicians commonly manage many noncomplicated (ie, segmental or smaller) PEs in an ED and that the prevalence of complicated PE is usually lower. We also noticed that the measurement of cTnI was not blind to the emergency physician nor to the cardiac technician/physician, introducing biases [2]. Furthermore, their criteria for thrombolysis in the institution are not detailed. It seems that right ventricular (RV) dysfunction