The Art of Medical Communications (Part 1 of 3: Talking Heads)

Every medical provider gathers important information from and about patients. EMS providers in particular are in a unique position to identify and collect data that no one else in the patient’s chain of care can get. This information may lead EMS personnel to provide certain treatments or may influence the patient’s work-up in the emergency department or hospital. However, if this information isn’t shared, it doesn’t just make it harder for other clinicians to figure out what is going on; patients may end up getting expensive and potentially dangerous work-ups and treatments they don’t need.

Medical communications are critical. Failing to provide a pre-arrival notification report, failing to perform a face-to-face handoff in the emergency department, and failing to complete a written patient care report in a timely manner are all breaches in the standard of practice in most EMS systems. Therefore, all providers will provide a pre-arrival report (by radio or telephone), a face-to-face patient handoff to a nurse, a physician, or their designee, and leave a written report (either a completed Run Report or an approved short form). Of course, there may always be reasonable explanations why reports were not performed (for example, no one at the hospital answers the radio after two attempts) but these should be properly documented on an incident report if they occur.

So, let’s talk about medical communications. For now we will focus on the pre-arrival notification and face-to-face handoff reports. The remaining two parts of this series will look at written communications (Part 2) and really, really important observations for you to pass along (Part 3).

Why do you give a pre-arrival notification report? Your notification gives the emergency department time to do whatever needs to be done to prepare for the patient’s arrival and to get you through the process and out as efficiently as possible. The content of the report should be limited to exactly what the ED needs to know to be ready for you. Minimum content includes identification of your unit, patient age and gender, chief complaint, any relevant history of present illness, any relevant past medical history, the most recent set of vital signs and any previous significant vital signs, any relevant physical exam findings, your treatments and the patient’s response, and an estimated time of arrival. The whole report should take under 45 seconds.

Looking at each of the elements of the pre-arrival notification:

Unit ID: The ED needs to know which unit is bringing in what patient when multiple ambulances arrive at the same time.

Age and gender: Different resources may be needed depending on the patient’s age. The gender is another identifier to make sure we don’t confuse patients. If you are calling on a phone, providing the patient’s name and date of birth as well may allow the ED to access the patient’s record prior to arrival and even preregister the patient.

Chief complaint: So the ED knows why the patient is coming. This can also include a very specific finding such as “This is a 43 year old male patient with chest pain whose 12 lead shows an anterior STEMI.”

Relevant History of Present Illness: This helps to clarify the chief complaint. For example, if the chief complaint is back pain, it makes a difference if it is non-traumatic or if the patient fell 20 feet off his roof. The same is true for chest pain, abdominal pain, shortness of breath, and just about any complaint you can think of.

Relevant past medical history: This also clarifies the complaint. If a patient is hypoglycemic, it makes a difference if he has a history of diabetes. It doesn’t matter if he broke his leg 3 years ago, at least not in terms of preparing for his arrival.

Most recent set of vital signs and previous significant vital signs: Again, this helps to differentiate patients who require more resources on arrival. Relevant trends are important because knowing that a patient was hypotensive and got better after a fluid bolus or that a patient had a normal heart rate and now has a heart rate of 30 helps the ED to prepare.

Relevant physical exam findings: Only if they’ll change management. If the patient is short of breath and has crackles on exam, that finding helps the ED to prepare (call respiratory for BiPAP, etc). If the patient injured his ankle, is a smoker and has bibasilar crackles, the finding of bibasilar crackles is not relevant to preparing for the patient. On the other hand, if that patient has no pulses and the ankle is deformed, that information is relevant.

Treatment and responses: If the patient was in SVT and you gave adenosine and fixed him, that’s good to know. If the patient had a systolic blood pressure of 50 and you dumped in a liter of fluid and his pressure is still 50, that’s also good to know. Again, it’s what helps set the context for the patient’s immediate treatment needs on arrival.

ETA: It tells us how quickly we need to put down our coffee…

So what happens when you don’t give a pre-arrival report? First, it interrupts the triage flow and delays someone getting you to the right place. While some EDs in the US are so busy that they have a nurse assigned to EMS triage, that is not usually the case. So the charge nurse has to direct the triage nurse or a flex (float, pick your title) nurse to triage your patient and you end up waiting longer for someone to take your patient. Second, if your patient needs an intervention immediately (even something as simple as a nose clip for epistaxis), it takes longer to make that intervention than it would if the ED had time to prepare. Thirdly, in EDs with limited or one clinician, if you deliver a sick patient without warning, that clinician may have just started a procedure on one of the 6 to 12 patients he is managing; it is better to delay starting a procedure or pause it in a controlled fashion than to have to interrupt it suddenly.

Now, the face-to-face handoff report is particularly important. Unless you turn your patient directly over to someone else, you are abandoning him. That’s right, once you assume care of your patient you have responsibility for him until someone takes over. This can be very frustrating when you have a low acuity patient and the ED appears to be falling apart so you’re standing with the patient doing nothing, but there are plenty of case reports of EMS providers making life saving interventions in the ED before they turned their patient’s over; conversely, there are case reports (and quality improvement cases) of patients suffering poor outcomes because they were “dumped” by EMS providers in an ED without a formal handoff.

So what is the content of the face-to-face handoff? It is similar to the pre-arrival report with more detail and an update. The minimum content would include (when known) the patient name, age, and gender, chief complaint, more detailed HPI, past medical history, medications, allergies, examination findings including vital signs and any relevant vital sign trends, treatments and responses, and any relevant update from the pre-arrival report not already covered.

Looking at each of the elements of the face-to-face report:

Patient name, age and gender: All the same reasons as the pre-arrival report

Chief complaint: So everyone caring for the patient is on the same page. Remember that many times the nurse or physician receiving the patient is not the same person who took the radio report.

HPI: Here you want to give a complete “Onset, Provoking /Palliating, Quality, Radiation, Severity, Timing” (OPQRST) type of report
Past Medical History: While it doesn’t need to be comprehensive, hit the major medical issues.

Medications: If the patient is on a lot, just name the relevant ones (warfarin in someone who is bleeding or frankly anyone who is taking it, albuterol in someone with shortness of breath, glyburide in someone with hypegrlycemia, etc.) and give the nurse a list. If the patient is only on a few medications, verbally report the full list.

Allergies: You may be the only one to get a complete list. If there are one or two, report them verbally. If the patient provided you with a list, pass on a copy of the list.

Examination findings: These can be broad. Report things relevant to the chief complaint but also report any other positive findings like “There’s a decubitus ulcer on the patient’s back” or “There’s some kind of rash on the legs.” Although these things may be found on the exam, knowing them ahead of time increases awareness. For vital signs, report the most recent set and any relevant trends. For trauma patients, be sure to report the highest heart rate and lowest blood pressure as well.

Treatments and response: What did you do and how did the patient respond to the treatment. We prefer treatment to be continuous rather than repetitive so knowing what is already done avoids duplication in the emergency department.

Any updates: These should have been covered by the rest of the face-to-face handoff report but it’s always good to make sure you haven’t left out anything else.

The information you give verbally to the emergency department may be the most accurate information available in a timely fashion. Remember that what you report may dictate the work-up the patient receives. Try to be complete and accurate.

Long and short? Do pre-arrival notifications, even for patients you identify as low acuity and make sure you don’t abandon patients by failing to give a good patient handoff report.

Be safe, play well with others and remember: we help people.

Additional Resources:
“Chapter 14: Communications” in Bledsoe BE, Porter RS, Cherry RA, eds. Essentials of Paramedic Care. 2nd ed. Pearson Education inc., Upper Saddle River. 2007. Pp. 716-34.