Hospital medicine in general, and inpatient trauma care specifically, is now characterized by a series of handoffs. These occur between physicians, trainees, nurses, and a host of other trauma professionals. Many trauma centers have implemented a “morning report” type of handoff, which formalizes part of the process and frequently adds a teaching component.
The group at the University of Arkansas studied the impact of implementing a morning report process on length of stay and care planning. Prior to the study, residents handed off care post-call to other residents without attending surgeon involvement. The morning report process added the presence of the post-call surgeon, and the trauma and emergency general surgery attendings coming on duty. Advanced practice nurses collected information on care plan changes.
Here are the factoids:
Problem: There is mention of a survey with 79% response rate detailing 219 trauma admissions during the 90 day study period. This is not explained anywhere else in the abstract, so it is not clear if the data presented represents all admissions.
69% of patients were admitted to a ward bed, and 31% to ICU
Change to the care plan occurred during morning report in 20% of patients
The most common care plan changes were: addition of a procedure in 45%, medication change in 34% (typically pain management)
Mean hospital length of stay decreased from 10 to 6 days (!)
Bottom line: This small, prospective study quantifies a few of the benefits of a formal “morning report” process. The fact that just a little bit of trauma attending oversight decreased length of stay by a whopping 4 days suggests that the residents really needed the increased supervision. Discharge planning is a multidisciplinary activity, and should be a major part of the rounding routine as well.
Formalizing the handoff process is always a good thing. Yes, it takes time and planning, but as this and other studies have shown, it is well worth the effort!
Morning report decreases length of stay in trauma patients by changing care plans in 20% of patients. AAST 2016, Poster 124.
Morning report decreases length of stay in trauma patients. Trauma Surg Acute Care Open 3(1):e185, 2018.
Damage control is over 25 years old already! We continue to refine the techniques and closure techniques/devices, and have developed novel ways to speed closure of the abdominal wall in order to avoid pesky hernias. But the process itself is time intensive, and typically several days pass with regular returns to OR until closure is achieved. This is one of the prime areas in which human error can occur, especially with modern service-style coverage of trauma patients.
In the old days, trauma patients were admitted by their surgeon, and that person provided their care nearly continuously until discharge. He or she rounded on them daily, took them back to the OR when needed, and then discharged them.
This is less practical (and desirable) in this day and age. And even if it seems possible, it’s not. No one can be on call 24 hours a day, and provide comprehensive care to every patient, around the clock. Many trauma programs have adopted a “service model”, where patients are admitted to a defined care team and managed by them. The team is led by a surgeon, but that person may change on a weekly (or in some cases nearly daily) basis. I call this the “interchangeable head” model, and to make it work there must be excellent handoffs during any leadership change.
In some cases, a patient may undergo a damage control procedure by one surgeon, but another must do the takeback and possibly the definitive closure. In this case, the handoff is critical! It is paramount that the next surgeon know everything about the first case so that they can perform the correct procedure.
How can this be accomplished? Here are some tips:
Do not rely on the medical record and previous operative note. It may not be available, and there is usually some loss of information in recording it anyway. Don’t believe it.
Ideally, meet face to face with the previous surgeon(s). Get the blow by blow description of exactly everything that was done and how. Also discuss what still needs to be done, and when. Try to maintain a uniform philosophy of patient care across surgeons.
If face to face is not possible, a telephone call is acceptable. The discussion is exactly the same.
If the surgery occurred at an outside hospital and was then transferred, you must call the initial surgeon to have this discussion before going to the OR!
If something unexpected is encountered during the case, make sure you have contact information so you can call during the case.
Applying these concepts will decrease the possibility of error, as well as the likelihood of any iatrogenic harm to these complex patients.
Over the past two days, I’ve discussed a method for optimizing the hand-off process between prehospital providers and the trauma team. Besides improving the quality and completeness of information exchange, it also fosters a good relationship between the two. All too often, the medics feel that “the trauma team is not listening to me” if the procedure is to move the patient onto the ED bed as quickly as possible.
And they are right! As soon as the patient hits the table, the trauma team starts doing what they do so well. It’s impossible for humans to multi-task, even though they think they can (look at texting and driving). We switch contexts with our brain, from looking at the patient to listening to EMS, back and forth. And it takes a few extra seconds to switch from one to the other. Team members will not be able to concentrate on the potentially important details that are being relayed.
What should you do if the team doesn’t want to wait?
First, educate them. Except for those who are in extremis or arrest, the patient can wait on the EMS stretcher for 30 seconds. Nothing harmful is going to happen in that short period.
Then, create a hard stop. The easiest way to do this is to place a laminated copy of the timeout procedureon the ED bed. And the rule is that the card doesn’t move until the timeout is done. This is very similar to what happens in the OR. The process should take only 30 seconds, then it’s over and the team can start.
I wrote about handoffs between EMS and the trauma team yesterday. It’s a problem at many hospitals. So what to do?
Let’s learn from our experience in the OR. Best practice in the operating room mandates a specific time out process that involves everyone in the OR. Each participant in the operation has to stop, identify the patient, state what the proposed procedure and location is, verify that the site is marked properly, and that they have carried out their own specific responsibilities (e.g. infused the antibiotic).
Some trauma centers have initiated a similar process for their trauma team as well. Here’s how it works:
The patient is rolled into the resuscitation room by EMS personnel, but remains on the stretcher.
Any urgent cares continue, such as ventilation.
The trauma team leader is identified and the EMS lead gives a brief report while everyone in the room listens. The report consists of only mechanism, all identified injuries, vital signs (including pupils and GCS), any treatments provided. This should take no more than 30 seconds.
An opportunity for questions to be asked and answered is presented
The patient is moved onto the hospital bed and evaluation and treatment proceed as usual.
EMS personnel provide any additional information to the scribe, and may be available to answer any additional questions for a brief period of time.
Bottom line: This is an excellent way to improve the relationship between prehospital and trauma team while improving patient care. It should help increase the amount of clinically relevant information exchanged between care providers. Obviously, there will be certain cases where such a clean process is not possible (e.g. CPR in progress). I recommend that all trauma programs consider implementing this “Trauma Activation Time Out For EMS” concept.
Tomorrow, I’ll share a best practice to make this process even better!
Handoffs occur in trauma care all the time. EMS hands the patient off to the trauma team. ED physicians hand off to each other at end of shift. They also hand off patients to the inpatient trauma service. Residents on the trauma service hand off to other residents at the end of their call shift. Attending surgeons hand off to each other as they change service or a call night ends. The same process also occurs with many of the other disciplines involved in patient care as well.
Every one of these handoffs is a potential problem. Our business is incredibly complicated, and given that dozens of details on dozens of patients need to be passed on, the opportunity for error is always present. And the fact that resident work hours are becoming more and more limited increases the need for handoffs and the number of potential errors.
Today, I’ll look at information transfer at the first handoff point, EMS to trauma team. Some literature has suggested that there are 16 specific prehospital data points that affect patient outcome and must be included in the EMS report. How good are we at making sure this happens?
An observational study was carried out at a US Level I trauma center with video recording capabilities in the resuscitation room. Video was reviewed to document the “transmission” part of the EMS report. Trauma chart documentation was also reviewed to see if the “reception” half of the process by the trauma team occurred as well.
Here are the factoids:
A total of 96 handoffs were reviewed over a one year period
The maximum number of data elements in the study was 1536 (96 patients x 16 data elements)
The total number “transmitted” was 473, but only 329 of those were “received.”
This is not quite as bad as it seems, since 483 points were judged as not applicable by the reviewers. However, this left 580 that were applicable but were not mentioned by EMS.
Of the 16 key elements, the median number transmitted was 5, with a range of 1-9.
This sounds bad. However, the EMS professionals and the physicians have somewhat different objectives. EMS desperately wants to share what they know about the scene and the patient. The trauma team wants to start the evaluation process using their own eyes and hands. What to do?
Bottom line: EMS to trauma team handoffs are a problem for many hospitals. EMS has a lot of valuable information, and the trauma team wants to keep the patient alive. They are both immersed in their own world, working to do what they think is best for the patient. Unfortunately, they could do better if the just worked together a bit more.
Tomorrow I’ll share a solution to the EMS-trauma team handoff problem.
Reference: Information loss in emergency medical services handover of trauma patients. Prehosp Emerg Care 13:280-285, 2009.
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