“Handover of care is one of the most perilous procedures in medicine, and when carried out improperly can be a major contributory factor to subsequent error and harm to patients.” – Professor Sir John Lilleyman, Medical Director, National Patient Safety Agency, UK
Scenario
A patient with blunt traumatic brain injury was intubated prehospital using Ketamine and Rocuronium, (thank you @ketaminh). The patient was placed on a ventilator, post-intubation analgesia and sedation was administered, ETCO2 was maintained at 38mmHg and the patient was transported to Ubuntu Hospital. On arrival at Ubuntu: the patient was verbally handed over to the registered nurse and emergency centre doctor and copies of EMS documentation taken to the reception area to ‘open a file’ (which is standard practice across many South African healthcare facilities).
The team jumped straight into patient care and paid very little attention to the handover given. About 20 minutes later I overheard them discussing that the patient was not a candidate for CT Scan or Neurosurgery intervention due to the GCS of 2T. I politely reminded them of the Rocuronium given 20 minutes prior.
The training, capability and scope of practice of South African out-of-hospital practitioners have increased dramatically over the last 10 years allowing practitioners to perform more complicated interventions, such as rapid sequence intubation (RSI) and thrombolysis. This does however bring a new safety concern to light. There is a vast amount of literature and discussion in Emergency Medicine & Patient Safety circles regarding the dangers of hand-over as a high risk arena. The majority of literature surrounds internal handover practices inside hospital with significantly less on EMS handover. Verbal handover is a skill that as EMS providers should become just as proficient with as they are with intravenous access. Experience alone does not by default give proficiency in this skill, which could arguably been viewed as an art rather than a skill. A novice paramedic may initially be mistaken in thinking that a good handover includes every detail of the entire patient care journey, when instead it is a brief summary of only important positives and negatives.
Correct team members present:
Before starting your handover it is critical to ensure that you are, in fact, handing over to the correct person. I have, on more than one occasion, given my entire detailed handover to someone, only to discover 10 minutes later that this was a medical student or doctor from unrelated speciality. Also ensure from the EMS team only one person is assigned to give verbal handover to keep messages clear. Classic example is a junior EMS staff member who is busy in the sluice room cleaning equipment before leaving, and doctor ‘popping in’ to confirm points that they forgot from handover, risk of incorrect information being conveyed.
“Healthcare professionals sometimes try to give verbal handovers at the same time as the team taking over the patient’s care are setting up vital life support and monitoring equipment. Unless both teams are able to concentrate on the handover of a sick patient, valuable information will be lost.” – Junior Doctors Committee, British Medical Association
Structured approach – DeMIST PAD
The Emergency Medicine Society of South Africa (@emmsaorgza) has recommended a standard approach using the pneumonic DeMIST, we would like to disseminate this tool further (with slight #badEM twist to DeMISTPAD).
Demographics Age, estimated weight (if paediatric), location of pick up, presence of accompanying family member, relevant chronic illnesses/allergies
Mechanism or insult that occurred.
Injuries – Use a Head—>Toe Approach
Signs & symptoms Vital signs.
Treatment provided for the patient. Consider using the ABCDE approach to listing this
Pending urgent interventions (EMS perspective)
Interventions that EMS recognise need to be done as a priority but no time in ambulance – e.g. IV line or ETT currently needs re-securing (strapping loose), another dose analgesia/sedation needed now,
Adverse events – eg. important to handover if airway was CL4, possible tooth aspiration during intubation, incorrect dosing,
Documentation
Needs to be left behind (& legible!) – this is not only critical from a medico-legal perspective but also for team members who arrive later in the patients care journey who were not present for verbal handover. A good example would be a neurosurgeon who would like to review the GCS on scene & presence of absence of a hemiplegia prior to intubation / sedation / paralysis. In patients not falling into ‘Red’ triage category, frequently the doctor who takes your verbal handover may not ultimately end up treating the patient as the patient gets triaged and joins the ‘queue’, so it is important to include all pertinent facts onto paperwork.
Are you RECEIVING handovers from EMS?
Great advice from Natalie May summarised below (@_NMay) from @stemlyns – (read full article here for detail)
Sit Up = Pay attention, active listener, ask others to be quiet
Shut Up = Don’t interrupt
Sure Up = Once verbal handover complete – ask any remaining questions you have
Sum Up = Make your own verbal summary for EMS staff to ensure you understood correctly
Supplement = Make sure you go on later to read EMS notes.
- Troyer L, Brady W. Barriers to effective EMS to emergency department information transfer at patient handover: A systematic review. Am J Emerg Med [Internet]. Elsevier Inc.; 2020;38(7):1494–503. Available from: https://doi.org/10.1016/j.ajem.2020.04.036
- http://stemlynsblog.org/chinese-whispers-miscommunication-and-handover/
- Ashley Liebig at Resuscitate NYC17. St.Emlyn’s,” in St.Emlyn’s, January 20, 2017, https://www.stemlynsblog.org/ashley-liebig-at-resuscitate-nyc17-st-emlyns/
- Makkink AW, Stein COA, Bruijns SR, Gottschalk S. The variables perceived to be important during patient handover by South African prehospital care providers. African J Emerg Med [Internet]. Elsevier B.V.; 2019;9(2):87–90. Available from: https://doi.org/10.1016/j.afjem.2019.01.014
