We assessed hospital doctors’ perception of the ambulance services’ written records, and the actual transfer of data to the hospital EPR. We selected only parameters outside normal ranges and medical treatment actually provided by the pre-hospital team in order to focus on data with potential importance for the clinical course. We found that less than half of the information was transferred to the attending doctor’s admission note, which is the primary compilation of information about the present medical history and clinical findings in the EPR. This finding is disturbing if it reflects a discontinuity in care of the emergency patient[3, 5, 6].
Other authors have discussed challenges to good communication between ambulance staff and the ED department clinicians. According to Yong et al. only half of the clinicians referred to the ambulance records, even though they perceived handover information as useful, consistent with the our findings. Thakore and Morrison reported that the ED medical staff found handover quality variable and lacking structure, whereas ambulance crews felt that medical staff did not pay attention to their handovers. Interdisciplinary training in handover skills, development of standardised formats, active listening skills and even electronic transfer of pre-hospital data have been suggested to improve accuracy and completeness in ED handovers[2, 4, 7, 16–19]. Even though standardised communication guidelines to increase patient safety have been recommended by some authors, they are in limited use and positive effects have still not been documented. The usefulness of electronic pre-hospital records has been limited, mostly because they have been difficult to integrate with intra-hospital EPRs. In our hospital, no standardised handover protocol is in use, and the pre-hospital records are not part of the EPR.
Only half of the positive findings documented in the PRF were actually reported in the EMCC records. Still, the fact that information is included in the PRF does not imply that it was transmitted during the brief radio or telephone report before admission. It is probably acceptable that the ambulance crew reduces the amount of information to an appropriate minimum and understandable if EMCC staff omits parts of the transmitted data in their report.
Hospital clinicians preferred the written note from the admitting GP. It is tempting to believe that the clinicians found the structure or format of this note familiar, and resembling the admission note they write in the EPR when compared with the PRF, which is focused on vital signs reporting. It is evident from our results that the doctors emphasise the observations made by the physician manned HEMS significantly more than observations from the technician or paramedic manned ground ambulance service. The notes from the ED nurses was least emphasised of all, probably because they contain only second hand information already conveyed to the clinician by the pre-hospital personnel.
It is interesting to note that the attending doctors prefer the verbal handovers as the main source for information, and not the written or scanned documents. The scanned files are included chronologically with the other notes in the EPR, but the legibility of the picture-file may not be as good as the original document. Thus, the scanned documents may primarily serve as permanent storage of the documentation and to a lesser extent, as a practical source of pre-hospital information. The response rate to the questionnaire was less than 50%, which is disappointing but not an uncommon observation. Web based questionnaires are commonly used in our hospital, and low response rates are often seen, probably because they are considered time consuming. We believe that a selection bias of importance for our study was unlikely if lack of time to participate was the main reason for not answering the survey. However, the possibility of bias cannot be ruled out completely.
The HEMS physicians may chose to write a pre-hospital note in the EPR to document critically important pre-hospital information, advanced treatment, and other information that is considered as important to the hospital staff. This kind of documentation is confined to a limited number of the HEMS patients. Only 8 out of 122 patients in our study had a HEMS note in the EPR. However, we observed that transfer of pre-hospital data to the EPR admission note was more complete in these cases (data not shown). It may theoretically reflect more severe disease or trauma in these 8 patients and the finding may not be explained by the format of the record alone. We still believe that pre-hospital notes written directly into the EPR could represent a format that would be easier to access and preferred as source of information by hospital clinicians.
When analysing the transfer to EPR of the individual parameters we found that information about mechanism of injury and administered drugs were transferred more often than vital signs. It could be that the pre-hospital vital signs observations were found to be unchanged in the ED and thus were considered unnecessary. Nevertheless, the dynamic nature of the pathophysiology of the emergency patient should advocate better documentation of the time course of vital signs.
The clinicians perceived the pre-hospital respiratory rate as the most important parameter, yet only transferred this information in less than 20% of the cases. Respiratory rate carries more prognostic information for trauma patients than any other single parameter. Still it is often not documented in patient records, even for severely traumatised patients. We have focused on better documentation of respiratory rate in our hospital for years, and believe that changes in respiratory rate is important for interpretation of the dynamic changes in the patient’s physiologic state.
Another important observation in our study is that the level of consciousness (GCS) was transferred clearly more often from patients admitted by the HEMS than by ground ambulance. It may be that the patient groups differ with regard to severity and frequency of trauma, but to some extent it may also reflect that a physician-scored GCS was perceived as more significant than GCS scored by ambulance staff. The ED clinicians did not regard information about mechanism of injury as very important in the questionnaire, but these data were almost always transferred to the EPR. This may be explained by the fact that also doctors that not see trauma patients participated in the questionnaire. When we analysed for differences between physicians, paediatricians and surgeons, we found that surgeons emphasised mechanism of injury far more than average.
It has been described earlier that pre-hospital data can be changed during transfer, so that the hospital records contain incorrect information. We have occasionally noted this in our ED department, but this has not been investigated by the present study.
The data that were not transferred from the PRF may represent information with no impact on clinical decisions, and thus our findings may have more medico-legal importance than clinical consequences. Our study design does not allow us to detail this question and this possibility will have to be addressed in future studies. We have raised several issues that should be investigated, for instance the clinical consequences of omitting information, and the flow of verbal information and its use in clinical decisions. However, the findings suggest that there is room for improvement in the handover of emergency patients in our setting.