Assessing North Texas Regional Trauma Handoffs: A Multicenter Mixed-Methods Needs Assessment

Abstract

Introduction

Trauma video review of Emergency Medical Services (EMS) handoffs demonstrates frequent problems including interruptions and incomplete information transfer. This study aimed to perform a regional needs assessment of handoff perceptions and expectations to guide future standardization efforts.

Methods

A multidisciplinary team of trauma providers through consensus building created an anonymous survey which was then distributed through the North Central Texas Trauma Regional Advisory Council and four regional level-1 trauma institutions. Qualitative data underwent content analysis; quantitative data are presented with descriptive statistics.

Results

Survey responses (n = 249) were submitted by trauma nurses (38%), EMS (24%), emergency physicians (14%), and trauma physicians (13%). Median overall handoff quality was rated well (4, scale 1-5) despite some variability between hospitals (3, scale 1-5). The top five most important handoff details were the same for both stable and unstable patients: primary mechanism, blood pressure, heart rate, Glasgow Coma Scale, and location of injuries. While providers felt neutral about the data order, the vast majority supported immediate bed transfer and primary survey in unstable patients. The majority of receiving providers report interrupting handoff at least once (78%); and 66% of EMS clinicians found interruptions disruptive. Content analysis revealed top priority categories for improvement: environment, communication, information relayed, team dynamics, and flow of care.

Conclusion

Although our data demonstrated satisfaction and concordance with respect to the EMS handoff, 84% of EMS clinicians reported some to high amounts of variability across institutions. Gaps in the development of standardized handoffs identified include exposure, education, and enforcement of these protocols.

Introduction

The handoff process–the communication and subsequent transfer of patient care–has been identified by the Joint Commission as a major contributor to sentinel events and thereby is a consistent target of quality improvement efforts.^1,2 Early studies demonstrated that in high-acuity environments, handoffs are highly variable in the completeness of information transfer, timeliness, and quality of communication.3, 4, 5, 6, 7 More specifically, critical information such as patient vital signs were missing at unacceptably high rates, interruptions and lack of closed-loop communication led to unnecessary repetition, and efficiency varied significantly when accounting for patient condition.8, 9, 10

As a high-stress, high-impact environment, the trauma handoff - which occurs between Emergency Medical Services (EMS) professionals and the receiving trauma team–is especially susceptible to variability.^9,11 Anecdotal inconsistency at our level-1 trauma center led the study team to evaluate nearly one hundred resuscitations using trauma video review (TVR). This process identified concerns similar to those published in literature including frequent interruptions, incomplete information transfer, and environmental factors that contribute to poor handoff quality.⁹ Hypothesizing that this variability exists regionally, we sought to perform a needs assessment evaluating the existing perceptions and protocols guiding EMS handoff.

In recent history, work in improving trauma patient-centered outcomes has led to the development and regionalization of trauma care through networks of prehospital care providers and specialized trauma centers. The ongoing goal of these networks is to optimize patient triage and standardize the quality of care across all institutions within a region.^12,13 Efforts to achieve this goal include trauma center verification through the American College of Surgeons (ACS) or state governments. Despite these efforts, the development of regionalized handoff protocols remains poorly implemented and studied. Only one previous study in central Ohio identified improvements in information transfer following the implementation of a standard handoff framework and training.¹⁴ Furthermore, the Eastern Association for the Surgery of Trauma (EAST) practice management guidelines for “Transitions of Care/Handoffs” is currently under development and areyet to be published.¹⁵

With this in mind, we sought to perform a needs assessment of the perceptions and expectations of the handoff process across North Texas to assist in the standardization of regional protocols. We included multiple stakeholder perspectives including emergency medical technicians (EMT), paramedics, emergency physicians (EP), trauma physicians, trauma nurses, and other trauma providers across multiple institutions.16, 17, 18 Beyond just the clinical content, we also evaluated the ideal duration, order of information, effective and ineffective environment characteristics, timing of adjunct patient care, and priorities for future optimization. We hypothesized that provider opinions would vary significantly between those receiving and providing handoff; however, we also hypothesized that expectations for an ideal handoff environment would be largely similar or overlapping in nature across all providers.