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Studer Spotlight: Effective Care Transitions from EMS to the Emergency Department

Posted on Wed, Jan 20, 2016
Studer Spotlight: Effective Care Transitions from EMS to the Emergency Department

Since 2010, EmCare has maintained a strong partnership with Studer Group to improve clinical and operational results for our client hospitals. As a result of this partnership, Studer Group has provided access to exclusive content only available on StuderGroup.com. Each month, one of Studer Group's insightful articles will be made available to emcare.com blog readers. For more information about EmCare's partnership with Studer Group, click here. For more exclusive content, including webinars, learning labs, networking opportunities and more, visit StuderGroup.com.

By Bob Murphy, RN, JD

Effective care transitions from Emergency Medical Services (EMS) to the Emergency Department (ED) are critical to providing safe and quality patient care. Both EMS and the ED team must develop the necessary skills to efficiently handover patients to provide appropriate care and has the potential to save lives and improve patient eligibility for time-sensitive therapies such as stroke or acute myocardial infarction care. Conversely, an Australian study showed that nearly one in 10 patients may be adversely affected as the result of poor handovers..

Effective care transitions actually start before a patient is even encountered. Here are a few important points:
 

  • EMS leaders and medical directors, working with ED physician leadership, should communicate regularly to plan, train and assess how transitions of care should be performed. They should agree on the minimum information expected to be shared about the patient from the scene, both en-route to the ED and upon arrival at the ED.
  • Mutual respect and an understanding of our roles is necessary. Both pre-hospital and ED teams work hard to do their best to care for patients and a recognition that we have different work environments, equipment, personnel resources and time pressures in which we provide care is critical. We are all members of the same team in providing excellent care.

Before the patient arrives at the ED:
EMS providers have a critical role in gathering and transferring essential information and should gather as much relevant information as feasible about the patient to share with ED providers. This includes:
 
  • Information that was available only to the EMS crew, including the patient’s living and social conditions (including indications of abuse or neglect), accident circumstances, key contacts, witnesses to events, and medication and problem lists.
  • When circumstances suggest that advance directives are in effect, EMS personnel should ask if a document is available and whether a copy can be transported with the patient.

While on scene or en-route to the ED, EMS agencies attempt to contact the ED by radio or phone. This brief report helps the ED staff know what resources to have in place when the patient arrives and can set the tone for the rest of the interaction and will impact care the patient receives.

The call by EMS should include:
 
  • A brief, but relevant history including why EMS was called and the chief complaint.
  • What EMS observed while on scene.
  • Relevant vital signs and assessment.
  • Treatment initiated so far and the patient’s response to treatment.


ED staff should respond to the call by EMS by:
 

  • Responding in a timely manner. This shows respect for the EMS crew.
  • Listening carefully.
  • If possible, assign a room number or treatment area so the crew and patient is not left waiting in a hallway when they arrive.
  • Using a professional tone. Remember, the EMS crew observed things you did not. And, the patient or family may be listening.


Upon arrival at the ED both EMS and ED staff should demonstrate professional behavior during announcement of patient arrival, history and handover of the patient. Below are some communication tips for both EMS and ED staff.

The EMS crew should:
 

  • Provide a succinct yet complete history of the patient.
  • Share any changes since the initial report.
  • Include additional information that may help the ED team.
  • Show gratitude and appreciation for the work of the ED team.
  • Transmit all information from pre-hospital EMS transports for real-time review and use, whether in print or electronically. This can be accomplished by equipping emergency departments with docking stations/printers compatible with EMS computers or by fully enabled electronic transfer to the department’s EMR system.


Upon arrival at the ED, the ED staff should:
 

  • Immediately assess each patient upon arrival and assign a bed or treatment location quickly. The EMS crew will likely be under pressure to get back in the field.
  • Keep a cordial tone and treat EMS team members with respect.
  • Be receptive to their findings and the individuals themselves.
  • Show gratitude and appreciation for the work of the EMS team. They may influence where patients receive care.


We also recommend both EMS and ED teams use Key Words at Key Times when completing care transitions. For example, the EMS team can introduce and manage up the ED caregivers by saying “Ms. Jones, you are in good hands with Dr. Smith and the ED team here.” The ED team can reciprocate by sharing “The paramedics did a great job in caring for you. We plan to continue that excellent care while you are in our emergency department.”

Our goal is to ensure a smooth and efficient transfer from prehospital care to Emergency Department care. This model of communication can decrease the risk of communication failures and improve the care we provide our patients. This also improves the working relationship between EMS and ED teams.

Sources:
"ACEP Transitions of Care Task Force Report." ACEP.org. September 1, 2012. Accessed December 6, 2015. http://www.acep.org/workarea/DownloadAsset.aspx?id=91206.

"Transfer of Patient Care Between EMS Providers and Receiving Facilities." ACEP.org. October 26, 2015. Accessed December 6, 2015. http://www.acep.org/Transfer-of-Patient-Care-Between-EMS-Providers-and-Receiving-Facilities/.

Ye K, Taylor D, Knott J, et al. Handover in the emergency department: Deficiencies and adverse effects. Emerg Med Australia. 2007;19(5):433–441.


Bob Murphy is a well-known senior leader and international healthcare presenter with more than 30 years in healthcare. His experience includes work as an EMT and Paramedic, phlebotomist, nursing assistant, registered nurse, department leader of emergency/trauma services, quality leader, risk manager, Chief Operating Officer, and hospital Chief Executive Officer. Murphy is also an attorney and is board certified in healthcare administration. Bob is now attending seminary and is pursuing a master’s degree in divinity.

Bob currently serves as a senior leader of Studer Group where he presents at healthcare conferences and seminars and coaches senior leadership teams.

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Documentation Tip of the Week: Stroke for ICD-10

Posted on Wed, Sep 30, 2015
Documentation Tip of the Week: Stroke for ICD-10

Our weekly feature of documentation tips for clinicians.

By Timothy Brundage, MD

ICD-10 is coming October 1st! Are you ready?

Key points in the documentation of stroke:

  • Laterality & Site (identify affected vessel)
  • Etiology (occlusion, hemorrhage, thrombosis, stenosis)
  • Underlying conditions (HTN, Atrial Fibrillation, etc.)
  • List any alcohol, drug, tobacco use/abuse/dependence
  • List tobacco exposure (second hand, occupational)

Hemiplegia is a comorbidity/complication (CC)
  • Document if dominant side for ICD-10

Document “history of stroke” only in the PMHx portion

“Sequelae” of stroke is preferred if there is a manifestation due to current/previous stroke:
  • Hemiplegia, as a sequelae of stroke
  • Aphasia, as a sequelae of stroke
  • Ataxia, as a sequelae of stroke



Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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More Progress Needed to Get Stroke Patients Rapid Care

Posted on Sat, Aug 08, 2015
More Progress Needed to Get Stroke Patients Rapid Care

Researchers find transport time to specialized center sometimes longer than two hours.

THURSDAY, Aug. 6, 2015 (HealthDay News) -- Stroke victims still aren't getting treated soon enough, a new study suggests. The findings were presented this week at the annual meeting of the Society of NeuroInterventional Surgery, held from July 27 to 30 in San Francisco.

Michael Froehler, M.D., and Kiersten Espaillat, D.N.P., of the Cerebrovascular Program at Vanderbilt University Medical Center in Nashville, Tenn., recorded the amount of time it took to transfer 70 patients from hospitals that were not equipped to handle all levels of stroke to major stroke centers.

Over the course of one year, the researchers found transfer times ranged between 46 and 133 minutes. Those times were longer than it would have taken to drive the distance between the facilities, the researchers noted.

Stroke is the number one cause of disability and the fourth leading cause of death in the United States, the researchers said. Stroke cost about $54 billion in health care expenses and lost productivity in 2010 alone. Disability-related health care expenses resulting from strokes also cost $74 billion each year, they noted.

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Regional Variation in Treatment of Ischemic Stroke

Posted on Sun, Jul 05, 2015
Regional Variation in Treatment of Ischemic Stroke

Region accounted for 7 to 8 percent of variation in thrombolysis treatment

THURSDAY, July 2, 2015 (HealthDay News) -- There is considerable regional variation in thrombolysis treatment for ischemic stroke, according to a study published online June 2 in Stroke.

Lesli E. Skolarus, M.D., from the University of Michigan in Ann Arbor, and colleagues conducted a retrospective cross-sectional study of all fee-for-service Medicare patients with ischemic stroke admitted via the emergency department from 2007 to 2010. Regional thrombolysis rates were estimated and the impact of patient demographics, regional factors, and elements of stroke systems of care on regional variation were investigated.

Over the four-year period there were 844,241 ischemic stroke admissions assigned to one of 3,436 hospital service areas; of these, 3.7 percent received intravenous tissue-type plasminogen activator and 0.5 percent received intra-arterial stroke treatment, with or without intravenous tissue-type plasminogen activator. The researchers observed variation in the unadjusted proportion of patients with ischemic stroke who received thrombolysis, from 9.3 to 0 percent in the highest versus lowest treatment quintiles. There was a weak association for measured demographic and stroke system factors with treatment rates. Region explained 7 to 8 percent of the range in receipt of thrombolysis. About 7,000 additional patients with ischemic stroke would be treated with thrombolysis if all regions performed at the level of the 75th percentile region.

"Future studies to determine features of high-performing thrombolysis treatment regions may identify opportunities to improve thrombolysis rates," the authors write.

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Hospitals Embracing 'Drip and Ship' Stroke Protocol

Posted on Sun, Feb 15, 2015
Hospitals Embracing 'Drip and Ship' Stroke Protocol

More local hospitals comfortable giving tPA drip, then shipping patients to advanced centers

WEDNESDAY, Feb. 11, 2015 (HealthDay News) -- More community hospitals are giving tissue plasminogen activator (tPA) medication to stroke victims, improving their chances of survival and recovery, new research indicates. The findings are to be presented Wednesday at the American Stroke Association's International Stroke Conference, held from Feb. 11 to 13 in Nashville, Tenn., and published simultaneously Feb. 11 in Stroke.

These local hospitals are becoming more comfortable using tPA due to a new treatment scheme known as "drip and ship," study author Kevin Sheth, M.D., chief of the neurocritical care and emergency neurology division at the Yale School of Medicine in New Haven, Conn., told HealthDay. "Drip and ship" means that front-line hospitals quickly administer tPA to people suffering an ischemic stroke, and then immediately transport them to a more advanced medical center with better stroke treatment facilities, Sheth explained.

Sheth and his team analyzed data on 44,667 ischemic stroke patients who received tPA within less than three hours at 1,440 hospitals between 2003 and 2010. Researchers compared "drip and ship" patients to those who received tPA at the hospital where they were admitted. The investigators found that 23.5 percent of patients receiving tPA quickly were treated using "drip and ship."

Until now, there had been no nationwide analysis to see whether community hospitals have accepted "drip and ship" as a treatment plan for stroke victims, Sheth said. Patients treated by "drip and ship" tended to be younger, more often male, and more often white, the study authors noted. Researchers also found that hospitals on the receiving end of "drip and ship" patients tended to have more beds, were more likely to be academic medical centers, more often had achieved certification as a designated stroke center, and maintained a higher volume of stroke cases per year. "I think we'll see even more 'drip and ship' in the coming years," Jeffrey Saver, M.D., director of the UCLA Comprehensive Stroke Center and spokesman for the American Heart Association/American Stroke Association, told HealthDay. "This study shows that it's a safe way to go."

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