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Communication between pre-hospital and intra-hospital emergency medical services: literature review

La comunicación entre los servicios médicos de emergencia pre-hospitalaria e intra-hospitalaria revisión de literatura

ABSTRACT

Objectives:

to analyze, according to the scientific literature, communication strategies in the transfer of cases between pre-hospital and in-hospital services and their contributions to patient safety.

Methods:

this is a literature review study, that is, one that aims to gather and synthesize research results on the subject in a systematic and orderly manner.

Results:

ten articles were published, published between 2010 and 2018, and two points of discussion emerged: use of mnemonics; and barriers to transferring a case.

Conclusions:

studies point to the need to standardize the case transfer process, as well as integrative training of professionals, regular assessment of the teams involved in emergency medical services and the need for research on the subject.

Descriptors:
Communication; Emergency Medical Services; Ambulance; Transfer of Responsibility by the Patient; Review

RESUMEN

Objetivos:

analizar, de acuerdo con la literatura científica, estrategias de comunicación en la transferencia de caso entre los servicios pre-hospitalaria e intra-hospitalariae sus contribuciones para la seguridad del paciente.

Métodos:

se trata de un estudio de revisión de literatura, es decir, aquel que tiene como finalidad reunir y sintetizar resultados de investigaciones sobre la temática de manera sistemática y ordenada.

Resultados:

han sido recogidos diez artículos, publicados entre 2010 y 2018, emergiendo dos puntos de discusión: uso de nemotécnicos; y barreras para la transferencia de caso.

Conclusiones:

los estudios apuntan para la necesidad de estandarización del proceso de transferencia de caso, así como entrenamiento integrador de los profesionales, evaluación regular de los equipos envueltos en los servicios médicos de emergencia y necesidad de investigación acerca de la temática.

Descriptores:
Comunicación; Servicios Médicos de Emergencia; Ambulancia; Transferencia de la Responsabilidad por el Paciente; Revisión

RESUMO

Objetivos:

analisar, de acordo com a literatura científica, estratégias de comunicação na transferência de caso entre os serviços pré-hospitalar e intra-hospitalar e suas contribuições para a segurança do paciente.

Métodos:

trata-se de um estudo de revisão de literatura, isto é, aqueleque tem como finalidade reunir e sintetizar resultados de pesquisas sobre a temática de maneira sistemática e ordenada.

Resultados:

foram selecionados dez artigos, publicados entre 2010 e 2018, emergindo dois pontos de discussão: uso de mnemônicos; e barreiras para a transferência de caso.

Conclusões:

os estudos apontam para a necessidade de padronização do processo de transferência de caso, bem como treinamento integrativo dos profissionais, avaliação regular das equipes envolvidas nos serviços médicos de emergência e necessidade de pesquisa acerca da temática.

Descritores:
Comunicação; Serviços Médicos de Emergência; Ambulância; Transferência da Responsabilidade pelo Paciente; Revisão

INTRODUCTION

Communication is a dynamic process and inherent to the nature of care. In health, it involves direct communication with the patient and also between professionals(11 Broca PV, Ferreira MA. A comunicação da equipe de enfermagem de uma enfermaria de clínica médica. Rev Bras Enferm. 2018;71(3):951-8. doi: 10.1590/0034-7167-2017-0208
https://doi.org/10.1590/0034-7167-2017-0...
), the latter being of great concern to bodies such as the World Health Organization (WHO) and the Joint Commission International (JCI), given that it is still a major source of errors, which can lead to adverse events compromising patient safety(22 Milesky JL, Baptiste D, Shelton BK. An observational study of patient handover communications among nurses on an oncology critical care unit. Contemp Nurse. 2018;54(1):77-87. doi: 10.1080/10376178.2017.1416306
https://doi.org/10.1080/10376178.2017.14...
-33 Maxfield DG, Lyndon A, Kennedy HP, Keeffe DO, Zlatnik MG. Confronting safety gaps across labor and delivery teams. Am J Obstet Gynecol. 2013;209(5):402-8. doi: 10.1016/j.ajog.2013.07.013
https://doi.org/10.1016/j.ajog.2013.07.0...
).

Both institutions joined forces to set goals that could reduce the negative impact of health actions on patients: the second goal is specifically about improving communication between health professionals(44 Rosa ERS, Oliveira GA, Freitas RBC, Mota SDA, Vitorio AMF. Metas internacionais de segurança do paciente na percepção de estudantes de enfermagem. Rev Rede Cuid Saúde [Internet]. 2017 &2019 Jun 06];11(1):1-3. Available from: http://publicacoes.unigranrio.edu.br/index.php/rcs/article/view/4587/2435.
http://publicacoes.unigranrio.edu.br/ind...
), because this is the most common cause of errors, generating deaths, high cost in hospital expenses, in addition to other factors, such as pain and sequelae to the patient(22 Milesky JL, Baptiste D, Shelton BK. An observational study of patient handover communications among nurses on an oncology critical care unit. Contemp Nurse. 2018;54(1):77-87. doi: 10.1080/10376178.2017.1416306
https://doi.org/10.1080/10376178.2017.14...
).

This scenario becomes even more serious when it comes to transferring the patient’s case between the pre-hospital and in-hospital stages of the emergency services. Due to the dynamic nature as well as the speed with which interventions must be carried out, communication can end up being impaired, directly causing delays and errors in diagnoses, treatment and in choosing the best conduct for the patient(55 Fealy G. Clinical handover practices among healthcare practitioners in acute care services: a qualitative study. J ClinNurs. 2018;28(1-2):80-8. doi: 10.1111/jocn.14643
https://doi.org/10.1111/jocn.14643...
).

When the communication process does not proceed properly, it fails in two distinct but predictable ways: silence and violence(33 Maxfield DG, Lyndon A, Kennedy HP, Keeffe DO, Zlatnik MG. Confronting safety gaps across labor and delivery teams. Am J Obstet Gynecol. 2013;209(5):402-8. doi: 10.1016/j.ajog.2013.07.013
https://doi.org/10.1016/j.ajog.2013.07.0...
,66 Deniz N, Noyan A, Ertosun ÖG. The relationship between employee silence and organizational commitment in a private healthcare company. Procedia Soc Behav Sci. 2013;99(6):691-700. doi: 10.1016/j.sbspro.2013.10.540
https://doi.org/10.1016/j.sbspro.2013.10...
). In the silence, important information and concerns are not passed on, or are passed on to the wrong people; and in violence, verbal attacks, sarcasm and other ways of labeling or disqualifying another professional can arise. These situations can be observed in different health professions and cause low commitment from professionals, weaken institutions and generate burdens.

Account must also be taken of the burden on emergency services, considering the pre-hospital and intra-hospital aspects, as well as structural problems and the weakness of the reference system, the latter, further hampered by the capacity of the doors of hospitals offering urgent and emergency services, with demands that could be met in Primary Health Care.

In addition, there is a difficulty in the training of health professionals and the lack of resources. These facts have a direct impact on the quality of care, as they add to the teams a greater workload and stress, considering also a chronic under-dimensioning of professionals from the most diverse areas(77 Tibães HBB. Perfil de Atendimento do Serviço de Atendimento Móvel de Urgência no Norte de Minas Gerais. Rev Pesqui: Cuid Fundam. 2018;10(3):675-82. doi: 10.9789/2175-5361.2018.v10i3.675-682
https://doi.org/10.9789/2175-5361.2018.v...
).

In Brazil, the mobile pre-hospital care system began to be structured based on Ordinance No. 2048, of November 25, 2002, which provided a solid basis for the organization of these services(88 Ministério da Saúde (BR). Portaria nº. 2048 05 de novembro de 2002. Aprova o regulamento técnico dos sistemas estaduais de urgência e emergência. Diário Oficial da União, Brasília, DF, 12 nov. 2002.). In 2003, the National Emergency Care Policy was created, culminating in the establishment of the Mobile Emergency Care Service (SAMU)(99 Soares MKP. Perfil dos usuários atendidos por um serviço pré-hospitalar móvel de urgência no nordeste brasileiro. Rev Pesqui: Cuid Fundam. 2018;0(2):503-9. doi: 10.9789/2175-5361.2018.v10i2.503-509
https://doi.org/10.9789/2175-5361.2018.v...
), where basic life support units are composed of at least one driver and a nursing technician; and advanced life support units are minimally composed of a doctor and a nurse, in addition to the driver(1010 Pai DD, Lima MADS, Abreu KP, Zucatti PB, Lautert L. Equipes e condições de trabalho nos serviços de atendimento pré-hospitalar móvel: revisão integrativa. Rev Eletron Enferm. 2015;17(4):1-12. doi: 10.5216/ree.v17i4.31522
https://doi.org/10.5216/ree.v17i4.31522...
).

Calls from the population to 192 are forwarded to a central office, where a technician receives the first information and passes it on to a regulatory doctor, which, according to the collected history, will decide what type of ambulance to send to the place and its final destination, always looking for a referral hospital for the situation found(1111 Santos MC, Bernardes A, Gabriel CS, Évora YDM, Rocha FLR. O processo comunicativo no Serviço de Atendimento Móvel de Urgência (SAMU-192). Rev Gaúcha Enferm[Internet]. 2012;33(1):69-76. doi: 10.1590/S1983-14472012000100010
https://doi.org/10.1590/S1983-1447201200...
).

Considering all the impact of communication from pre-hospital services to intra-hospital services, as well as the scarcity of the theme in the scientific literature, the relevance of this study stands out. In this sense, there is a lack of protocols that guide the transfer of the patient’s case between the segments of care, lack of training of professionals involved in this context, as well as the still recent action of trying to organize urgent and emergency services.

The following research question was then established: What are the main evidences about the communication between health professionals during the transfer of the case between the pre-hospital and in-hospital emergency services?

OBJECTIVES

To analyze, according to the scientific literature, communication strategies in the transfer of cases between pre-hospital and in-hospital services and their contributions to patient safety.

METHODS

Study type

This is a literature review study, that is, one whose purpose is to gather and synthesize research results on a certain topic or issue, in a systematic and orderly manner, contributing to the deepening of the investigated subject(1212 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008;17(4):758-64. doi: 10.1590/S0104-07072008000400018
https://doi.org/10.1590/S0104-0707200800...
). The review process followed the step by step of the research protocol “Main Items for Reporting Systematic Reviews and Meta-analyzes” (PRISMA)(1313 Principais itens para relatar Revisões sistemáticas e Meta-análises: a recomendação PRISMA. Epidemiol. Serv Saúde. 2015;24(2):335-42. doi: 10.5123/S1679-49742015000200017
https://doi.org/10.5123/S1679-4974201500...
), which is registered in the International Database of Systematic Review Protocols.

Methodological procedures

For the elaboration of this study, the following steps were delimited: identification of the theme and its delimitation (development of the research question, definition of the descriptors, inclusion and exclusion criteria of studies for the review); sampling; classification of studies; definition of the information to be extracted from the reviewed papers; analysis of the theme found in the literature; synthesis of the knowledge evidenced in the analyzed studies; and presentation of the integrative review(1212 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008;17(4):758-64. doi: 10.1590/S0104-07072008000400018
https://doi.org/10.1590/S0104-0707200800...
).

Data collection and organization

Data collection took place in January 2018, in the Web of Science, LILACS, Scopus, CINAHL and MEDLINE databases, using the Health Sciences Descriptors (DeCS) “Health Communication”, “Emergency Medical Services” and “Ambulance”, as well as the corresponding descriptors in English “Health Communication”, “Emergency Medical Services” and “Ambulance”.

The descriptors used were chosen because they were able to portray in a coherent and objective way what was identified in the searches. The descriptor “Communication in Health” corresponds to studies and communication strategies to inform decisions that promote health; o “Emergency Medical Services” is related to services that provide emergency care, such as pre-hospital care, SAMU, emergency centers, emergency rooms, among others; and “Ambulance” refers to vehicles equipped to transport patients. Thus, the articles that worked with the communication of the case transfer between the pre-hospital and in-hospital services were captured.

To elaborate the combinations between the descriptors, the Boolean operator “and” was used between them, according to the following search strategies: Health Communication “and” Ambulance “and” Emergency Medical Services; Health Communication “and” Ambulance; Health Communication “and” Emergency Medical Services; Ambulance “and” Emergency Medical Services; Health Communication “and” Ambulance “and” Emergency Medical Services; Health Communication “and” Ambulance; Health Communication “and” Emergency Medical Services; Ambulance “and” Emergency Medical Services; Health Communication “and” Ambulance “and” Emergency Medical Services; Health Communication “and” Ambulance; Health Communication “and” Emergency Medical Services; Ambulance “and” Emergency Medical Services; Health Communication “and” Ambulance “and” Emergency Medical Services; Health Communication “and” Ambulance; Health Communication “and” Emergency Medical Services; Ambulance “and” Emergency Medical Services; and Ambulance “and” Emergency Medical Services.

Data analysis

From the findings in the databases, 14,545 articles were found, which were evaluated by applying the inclusion and exclusion criteria previously defined in the research protocol. The inclusion criteria adopted were: be an original article and complete review; free access; have a maximum of ten years of publication; be written in Portuguese, English and Spanish; and having as a central theme the communication process in the transfer of cases between professionals in the mobile emergency medical service and the in-hospital.

Reflective studies, research protocols, editorials, letters to editors, duplicate studies were excluded, as well as those that addressed pre-hospital activity in relation to decision-making algorithms, ambulance redirection, assessment of communication systems and air rescue.

Thereafter, the 28 articles were read in full to identify those who answered the research question satisfactorily and / or had relevance to the study objectives. After this analysis, a sample of ten articles was obtained, including: eight (80%) from Web of Science and two (20%) from Scopus. The flowchart detailing the research steps is shown below, in Figure 1.

Figure 1
Flowchart of data collection and analysis, according to the PRISMA model(1313 Principais itens para relatar Revisões sistemáticas e Meta-análises: a recomendação PRISMA. Epidemiol. Serv Saúde. 2015;24(2):335-42. doi: 10.5123/S1679-49742015000200017
https://doi.org/10.5123/S1679-4974201500...
)

The data of the articles were organized in an Excel® table, in order to facilitate visualization for the analysis and interpretation of qualitative findings. This table contains a summary of the following information: title of the study, journal and year of publication, country of development of the study, study design, interventions and main outcomes. Based on the main interventions and outcomes, a qualitative analysis of this data was carried out, which supported the construction of the results and the discussion of this article.

RESULTS

The ten selected articles were published in English, being found in seven different magazines, with emphasis on the Scandinavian Journal Of Trauma, Resuscitation and Emergency Medicine, with three (30%) of the publications. As for the year, articles were published between 2010 and 2018, with emphasis on the years 2015, 2017 and 2018, each with two publications, representing, together, 60% of the selected articles.

Regarding the place of origin of the studies, there is a predominance of the European continent, accounting for eight articles, corresponding to 80% of publications, with the Netherlands responsible for three of these, representing 30%. As for the publication area, multiprofessional publications predominated, accounting for 50% of publications, followed by medical publications, which represent 40% of publications.

Regarding the type of study, those of a qualitative nature prevailed, totaling nine (90.0%) publications, and there was an article of a quantitative nature, corresponding to 10%. Regarding the level of evidence of the articles, it was established based on the type of methodological approach adopted(1414 Galvão CM, Sawada NO, Mendes IAC. A busca das melhores evidências. Rev Esc Enferm USP. 2003;37(4):43-50. doi: 10.1590/S0080-62342003000400005
https://doi.org/10.1590/S0080-6234200300...
): nine articles have evidence 4, representing 90%; and an article with level of evidence 2, representing 10%.

To facilitate the visualization of the results, Chart 2 presents the profile of the selected studies. Next, the two categories shown from the results of the selected studies are presented: use of mnemonic in the patient’s case transfer process; and barriers to transferring a case.

Chart 1
Profile of the studies selected by the research

Use of mnemonics in the patient’s case transfer process

Among the articles that present the use of mnemonics as a tool in patient transfer practices between pre-hospital and in-hospital teams, the term SBAR (Situation-Background-Assessment-Recommendation) stands out as being the most cited among the authors(1515 Hovenkamp GT. The satisfaction regarding handovers between ambulance and emergency department nurses: an observational study. Scand J Trauma ResuscEmerg Med. 2018;10;26(1):78. doi: 10.1186/s13049-018-0545-7
https://doi.org/10.1186/s13049-018-0545-...

16 Sanjuan A. Handover of patients from prehospital emergency services to emergency departments: a qualitative analysis based on experiences of nurses. J Nurs Care Qual. 2018;34(2):169-74. doi: 10.1097/NCQ. 0000000000000351
https://doi.org/10.1097/NCQ. 00000000000...
-1717 Kalyani MN, Fereidoun Z, Sarvestani RS, Shirazi ZH, Taghinezhad A. Perspectives of patient handover among paramedics and emergency department members; a qualitative study. Emerg (Tehran) [Internet]. 2017 [2019 Jun 06];5(1):e76. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5703753/
https://www.ncbi.nlm.nih.gov/pmc/article...
).

Also appear the terms MIST (injury/illness mechanism, sustained or suspected injury, signs, including observations and monitoring of the treatment given), ATMIST (age, time, injury / illness mechanism, sustained or suspected injury, signs, including observations and monitoring of treatment given), ABCDE (airway, breathing, circulation, disability and exposure) and AMPLE (allergy, medication, history, last meal, event)(1515 Hovenkamp GT. The satisfaction regarding handovers between ambulance and emergency department nurses: an observational study. Scand J Trauma ResuscEmerg Med. 2018;10;26(1):78. doi: 10.1186/s13049-018-0545-7
https://doi.org/10.1186/s13049-018-0545-...

16 Sanjuan A. Handover of patients from prehospital emergency services to emergency departments: a qualitative analysis based on experiences of nurses. J Nurs Care Qual. 2018;34(2):169-74. doi: 10.1097/NCQ. 0000000000000351
https://doi.org/10.1097/NCQ. 00000000000...
-1717 Kalyani MN, Fereidoun Z, Sarvestani RS, Shirazi ZH, Taghinezhad A. Perspectives of patient handover among paramedics and emergency department members; a qualitative study. Emerg (Tehran) [Internet]. 2017 [2019 Jun 06];5(1):e76. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5703753/
https://www.ncbi.nlm.nih.gov/pmc/article...
).

The isolated use of mnemonic does not understand all the aspects necessary for an adequate case transfer. When the term MIST is used, it requires other complementary data such as temperature, categorization of the elements of the Glasgow scale, important medications and allergies(1515 Hovenkamp GT. The satisfaction regarding handovers between ambulance and emergency department nurses: an observational study. Scand J Trauma ResuscEmerg Med. 2018;10;26(1):78. doi: 10.1186/s13049-018-0545-7
https://doi.org/10.1186/s13049-018-0545-...
). Likewise, the term ATMIST, which is widely used in guidelines related to resuscitation in the United Kingdom, must be accompanied by psychosocial aspects(2020 Sujan MA. Emergency Care Handover (ECHO study) across care boundaries: the need for joint decision making and consideration of psychosocial history. Emerg Med J. 2015;32(2):112-8. doi: 10.1136/emermed-2013-202977
https://doi.org/10.1136/emermed-2013-202...
). In addition, it is necessary to standardize the processes, in which the terms AMPLE and ABCDE are inserted in the protocols, given the positive correlation of satisfaction between professionals when these terms were used and when the transfer process was structured(1515 Hovenkamp GT. The satisfaction regarding handovers between ambulance and emergency department nurses: an observational study. Scand J Trauma ResuscEmerg Med. 2018;10;26(1):78. doi: 10.1186/s13049-018-0545-7
https://doi.org/10.1186/s13049-018-0545-...
).

To this end, it is recommended to conduct research in the area of pre-hospital emergency services aimed at informing transfer and feedback designs as well as health impacts when there is an improvement in communication, given the scarcity of literature showing the use of structured tools (using mnemonics) in order to improve communication during patient transfer of case(2424 Evans SM, Murray A, Patrick I, Fitzgerald M, Smith S, Cameron P. Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members. Qual Saf Health Care. 2010;19(6):e57. doi: 10.1136/qshc.2009.039073.
https://doi.org/10.1136/qshc.2009.039073...
).

Still, it must be considered that, for the implementation of new models of information transfer and feedback, some barriers must be broken: for example, the lack of a sense of urgency to improve, methods used in the process of implementing these models, as well as the existing routines in institutions, often described as highly stable, leading to institutional inertia(2222 Leijen-zeelenberg JEV. Barriers to implementation of a redesign of information transfer and feedback in acute care: results from a multiple case study. BMC Health Serv Res. 2014;3;14:149. doi: 10.1186/1472-6963-14-149
https://doi.org/10.1186/1472-6963-14-149...
).

Barriers to case transfer

Regarding the nurses’ satisfaction in the case transfer process, there is a negative correlation between satisfaction and the sharing of information about the patient, as there is no structured process. There is a lack of information, as well as a discrepancy between the data passed to the hospital before the patient’s arrival and his / her real state during the transfer of the case(1616 Sanjuan A. Handover of patients from prehospital emergency services to emergency departments: a qualitative analysis based on experiences of nurses. J Nurs Care Qual. 2018;34(2):169-74. doi: 10.1097/NCQ. 0000000000000351
https://doi.org/10.1097/NCQ. 00000000000...
).

The lack of leadership identification was also a problem identified(1616 Sanjuan A. Handover of patients from prehospital emergency services to emergency departments: a qualitative analysis based on experiences of nurses. J Nurs Care Qual. 2018;34(2):169-74. doi: 10.1097/NCQ. 0000000000000351
https://doi.org/10.1097/NCQ. 00000000000...

17 Kalyani MN, Fereidoun Z, Sarvestani RS, Shirazi ZH, Taghinezhad A. Perspectives of patient handover among paramedics and emergency department members; a qualitative study. Emerg (Tehran) [Internet]. 2017 [2019 Jun 06];5(1):e76. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5703753/
https://www.ncbi.nlm.nih.gov/pmc/article...

18 Flynn D, Francis R, Robalino S, Lally J, Snooks H, Rodgers H, et al. A review of enhanced paramedic roles during and after hospital handover of stroke, myocardial infarction and trauma patients. BMC Emerg Med. 2017;17(1):5. doi: 10.1186 / s12873-017-0118-5
https://doi.org/10.1186 / s12873-017-011...

19 Glind IVD. A national research agenda for pre-hospital emergency medical services in the Netherlands: a Delphi-study. Scand J Trauma ResuscEmerg Med. 2016;24: 2. doi: 10.1186/s13049-015-0195-y
https://doi.org/10.1186/s13049-015-0195-...

20 Sujan MA. Emergency Care Handover (ECHO study) across care boundaries: the need for joint decision making and consideration of psychosocial history. Emerg Med J. 2015;32(2):112-8. doi: 10.1136/emermed-2013-202977
https://doi.org/10.1136/emermed-2013-202...
-2121 Sujan MA. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy. 2014;20(1-Suppl):17-25. doi: 10.1177/1355819614560449
https://doi.org/10.1177/1355819614560449...
), in relation to which a study with 12 nurses showed the need to clearly identify to whom the case will be reported, since this is also a process of transferring responsibilities and essential for the continuity of care(1616 Sanjuan A. Handover of patients from prehospital emergency services to emergency departments: a qualitative analysis based on experiences of nurses. J Nurs Care Qual. 2018;34(2):169-74. doi: 10.1097/NCQ. 0000000000000351
https://doi.org/10.1097/NCQ. 00000000000...
). It is also pointed out that medical professionals of some specialties accept only patients who meet highly specific criteria, which can overburden the emergency department and lead to delays in care(2121 Sujan MA. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy. 2014;20(1-Suppl):17-25. doi: 10.1177/1355819614560449
https://doi.org/10.1177/1355819614560449...
).

Another important point to be highlighted is the lack of written information that could be consulted later(1515 Hovenkamp GT. The satisfaction regarding handovers between ambulance and emergency department nurses: an observational study. Scand J Trauma ResuscEmerg Med. 2018;10;26(1):78. doi: 10.1186/s13049-018-0545-7
https://doi.org/10.1186/s13049-018-0545-...
,2121 Sujan MA. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy. 2014;20(1-Suppl):17-25. doi: 10.1177/1355819614560449
https://doi.org/10.1177/1355819614560449...
-2222 Leijen-zeelenberg JEV. Barriers to implementation of a redesign of information transfer and feedback in acute care: results from a multiple case study. BMC Health Serv Res. 2014;3;14:149. doi: 10.1186/1472-6963-14-149
https://doi.org/10.1186/1472-6963-14-149...
). It was observed that ambulance professionals used mostly memory during the transfer of information in the transfer of the case and, when they documented it in writing, they did it in inappropriate places, such as gloves, loose sheets and bedding(1515 Hovenkamp GT. The satisfaction regarding handovers between ambulance and emergency department nurses: an observational study. Scand J Trauma ResuscEmerg Med. 2018;10;26(1):78. doi: 10.1186/s13049-018-0545-7
https://doi.org/10.1186/s13049-018-0545-...
).

Even when the information was documented in a standardized form, no more than 30% of the parameters covered were passed on to the hospital admission form; and, when the information was forwarded by link, data such as patient immobilization measures and fluids administered intravenously were passed on less than a third of the time(2323 Knutsen GO, Fredriksen K. Usage of documented pre-hospital observations in secondary care: a questionnaire study and retrospective comparison of records. Scand J Trauma Resusc Emerg Med. 2013; 1;21:13. doi: 10.1186/1757-7241-21-13
https://doi.org/10.1186/1757-7241-21-13...
). This occurs although the electronic transfer of data is seen as a way to improve the loss of information and avoid transcription errors(1515 Hovenkamp GT. The satisfaction regarding handovers between ambulance and emergency department nurses: an observational study. Scand J Trauma ResuscEmerg Med. 2018;10;26(1):78. doi: 10.1186/s13049-018-0545-7
https://doi.org/10.1186/s13049-018-0545-...
).

The importance of feedback on the transferred patient was also highlighted(1616 Sanjuan A. Handover of patients from prehospital emergency services to emergency departments: a qualitative analysis based on experiences of nurses. J Nurs Care Qual. 2018;34(2):169-74. doi: 10.1097/NCQ. 0000000000000351
https://doi.org/10.1097/NCQ. 00000000000...

17 Kalyani MN, Fereidoun Z, Sarvestani RS, Shirazi ZH, Taghinezhad A. Perspectives of patient handover among paramedics and emergency department members; a qualitative study. Emerg (Tehran) [Internet]. 2017 [2019 Jun 06];5(1):e76. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5703753/
https://www.ncbi.nlm.nih.gov/pmc/article...

18 Flynn D, Francis R, Robalino S, Lally J, Snooks H, Rodgers H, et al. A review of enhanced paramedic roles during and after hospital handover of stroke, myocardial infarction and trauma patients. BMC Emerg Med. 2017;17(1):5. doi: 10.1186 / s12873-017-0118-5
https://doi.org/10.1186 / s12873-017-011...

19 Glind IVD. A national research agenda for pre-hospital emergency medical services in the Netherlands: a Delphi-study. Scand J Trauma ResuscEmerg Med. 2016;24: 2. doi: 10.1186/s13049-015-0195-y
https://doi.org/10.1186/s13049-015-0195-...

20 Sujan MA. Emergency Care Handover (ECHO study) across care boundaries: the need for joint decision making and consideration of psychosocial history. Emerg Med J. 2015;32(2):112-8. doi: 10.1136/emermed-2013-202977
https://doi.org/10.1136/emermed-2013-202...

21 Sujan MA. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy. 2014;20(1-Suppl):17-25. doi: 10.1177/1355819614560449
https://doi.org/10.1177/1355819614560449...
-2222 Leijen-zeelenberg JEV. Barriers to implementation of a redesign of information transfer and feedback in acute care: results from a multiple case study. BMC Health Serv Res. 2014;3;14:149. doi: 10.1186/1472-6963-14-149
https://doi.org/10.1186/1472-6963-14-149...
): 43.4% of survey respondents point to the need for improved feedback as very urgent, which is indicated as more common among specialists than among specialists and ambulance professionals(2222 Leijen-zeelenberg JEV. Barriers to implementation of a redesign of information transfer and feedback in acute care: results from a multiple case study. BMC Health Serv Res. 2014;3;14:149. doi: 10.1186/1472-6963-14-149
https://doi.org/10.1186/1472-6963-14-149...
). This was also a topic presented as a research priority in countries like Canada, Australia and the United Kingdom(1919 Glind IVD. A national research agenda for pre-hospital emergency medical services in the Netherlands: a Delphi-study. Scand J Trauma ResuscEmerg Med. 2016;24: 2. doi: 10.1186/s13049-015-0195-y
https://doi.org/10.1186/s13049-015-0195-...
).

Another aspect to mention is the lack of physical and acoustic structure of the emergency departments, which disturbs the concentration of professionals involved at the time of passing the case, but it also removes the patient’s privacy, as anyone who approaches can hear the verbal transfer of confidential information(1717 Kalyani MN, Fereidoun Z, Sarvestani RS, Shirazi ZH, Taghinezhad A. Perspectives of patient handover among paramedics and emergency department members; a qualitative study. Emerg (Tehran) [Internet]. 2017 [2019 Jun 06];5(1):e76. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5703753/
https://www.ncbi.nlm.nih.gov/pmc/article...
).

Along with this, the time targets established by the unit managers are added to optimize care for victims: if, on the one hand, this pressure can create a corporate focus, on the other, it can favor the adoption of informal practices that can compromise patient safety(2121 Sujan MA. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy. 2014;20(1-Suppl):17-25. doi: 10.1177/1355819614560449
https://doi.org/10.1177/1355819614560449...
).

DISCUSSION

Based on the results presented, the use of mnemonics was obtained as a useful tool during case transfer; the most prominent term was SBAR, a validated and proven instrument for the transfer of information between health professionals. However, even this one needs modifications, giving rise to other terms such as ISBAR, in which the letter “I” refers to “identification”, in order to remind the professional to identify the patient and him/herself(2525 Alves M, Melo CL. Transferência de cuidado na perspectiva de profissionais de Enfermagem de um pronto-socorro. Rev Min Enferm. 2019;23:e-1194. doi: 10.5935/1415-2762.20190042
https://doi.org/10.5935/1415-2762.201900...
). Similar changes occur with the term MIST, in which the letters “A” and “T” were added (forming ATMIST), relating to the patient’s age and the time of the event(2626 Slope R. Military and civilian handover communication in emergency care: how does it differ?. J Paramedic Pract. 2018;11(2):66-73. doi: 10.12968/jpar.2019.11.2.66
https://doi.org/10.12968/jpar.2019.11.2....
).

As for the term ABCDE as a transfer tool, there is no consensus. In the Netherlands, the term is used to inform the transfer of case the same data as the advanced life support protocol(1515 Hovenkamp GT. The satisfaction regarding handovers between ambulance and emergency department nurses: an observational study. Scand J Trauma ResuscEmerg Med. 2018;10;26(1):78. doi: 10.1186/s13049-018-0545-7
https://doi.org/10.1186/s13049-018-0545-...
), whereas, in the UK, it was developed as a tool for shift change between teams, giving an overview of the sector(2727 Farhan M, Brown R, Woloshynowych M, Vincent C. The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department. Emerg Med J. 2012;29(12):941-6. doi: 10.1136/emermed-2011-200199
https://doi.org/10.1136/emermed-2011-200...
).

When carrying out a case transfer, it is also important to address the psychological and social aspects of patients(2020 Sujan MA. Emergency Care Handover (ECHO study) across care boundaries: the need for joint decision making and consideration of psychosocial history. Emerg Med J. 2015;32(2):112-8. doi: 10.1136/emermed-2013-202977
https://doi.org/10.1136/emermed-2013-202...
-2121 Sujan MA. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy. 2014;20(1-Suppl):17-25. doi: 10.1177/1355819614560449
https://doi.org/10.1177/1355819614560449...
), since most of those who arrive at the emergency department are elderly, this being a concern in the Brazilian scenario, because the epidemiological profile of those assisted in emergencies has been increasing due to the demand of this age group. Added to this, the reasons that lead such a group to this service, which are usually aggravations of chronic conditions, added to multiple comorbidities and changes in mental state(2828 Soares ALA, Santos SP, Corpolato RC, Willig MH, Mantovani MF. Elderly care in the emergency department: an integrative review. Rev Bras Geriatr Gerontol. 2018;21(2):243-53. doi: 10.1590/1981-22562018021.170144
https://doi.org/10.1590/1981-22562018021...
). These facts present themselves as barriers to care, since less than 3% of case transfers presented information about the psychosocial conditions of patients who arrived from the ambulance to the emergency department(2020 Sujan MA. Emergency Care Handover (ECHO study) across care boundaries: the need for joint decision making and consideration of psychosocial history. Emerg Med J. 2015;32(2):112-8. doi: 10.1136/emermed-2013-202977
https://doi.org/10.1136/emermed-2013-202...
).

The absence of psychosocial information is directly related to the interference of the institutions in the work process, so that the imposed time targets affect the quality of the case transfer. When trying to adapt to these goals, in order to pass the case on and return to the operational base, the professional who works in the ambulance ends up having to optimize the time and shorten the amount of information to be transmitted; because of this, psychological and social aspects are typically the most overlooked(2121 Sujan MA. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy. 2014;20(1-Suppl):17-25. doi: 10.1177/1355819614560449
https://doi.org/10.1177/1355819614560449...
).

Such aspects can be considered in the history stage of some mnemonics, such as that of SBAR and AMPLE. When caring, the professional needs to have an integral look at the patient, including all of his biopsychosocial aspects, even in an emergency situation.

With regard to the lack of established leadership at the time of delivery of the patient, there is: the lack of consensus to where the patient who lacks multiple specialties should be sent; and the refusal of the medical team to assist patients who do not meet strict health standards(2121 Sujan MA. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy. 2014;20(1-Suppl):17-25. doi: 10.1177/1355819614560449
https://doi.org/10.1177/1355819614560449...
). Such impediments can cause queues in the emergency services and increase the workload of ambulance professionals, who can only leave the place when some professional of the in-hospital service take on the patient(2929 Hovenkamp GT, Olgers TJ, Wortel RR, Noltes ME, Dercksen B, TerMaaten JC. The satisfaction regarding handovers between ambulance and emergency department nurses: an observational study. Scand J Trauma Resusc Emerg Med. 2018;26(1):78. doi: 10.1186/s13049-018-0545-7.
https://doi.org/10.1186/s13049-018-0545-...
).

Another important point that corroborates this problem is the multiple patient reception systems: in some places, the nurse is responsible for waiting for the pre-hospital service to arrive; in others, the doctor receives the team. However, there are places where no one is waiting: the ambulance professional has to enter the emergency service in search of leadership to transfer responsibility for the patient(1616 Sanjuan A. Handover of patients from prehospital emergency services to emergency departments: a qualitative analysis based on experiences of nurses. J Nurs Care Qual. 2018;34(2):169-74. doi: 10.1097/NCQ. 0000000000000351
https://doi.org/10.1097/NCQ. 00000000000...
).

As for the changes that can improve the processes and workflows predetermined by the institutions, the routines already established as a barrier can be cited, because there may be a stability of the transfer models and also an institutional inertia, the result of which is the plastering of the patient’s conduct of receiving cases(2222 Leijen-zeelenberg JEV. Barriers to implementation of a redesign of information transfer and feedback in acute care: results from a multiple case study. BMC Health Serv Res. 2014;3;14:149. doi: 10.1186/1472-6963-14-149
https://doi.org/10.1186/1472-6963-14-149...
).

The feedback of the information passed on has also been shown to be an important way to improve the transfer process since it allows determining the success of the communication(11 Broca PV, Ferreira MA. A comunicação da equipe de enfermagem de uma enfermaria de clínica médica. Rev Bras Enferm. 2018;71(3):951-8. doi: 10.1590/0034-7167-2017-0208
https://doi.org/10.1590/0034-7167-2017-0...
); however, it is not adopted as mandatory conduct by institutions. In addition, the perception of urgency of professionals involved in acute care is a factor that limits the scope of changes in the existing model for transferring cases(2222 Leijen-zeelenberg JEV. Barriers to implementation of a redesign of information transfer and feedback in acute care: results from a multiple case study. BMC Health Serv Res. 2014;3;14:149. doi: 10.1186/1472-6963-14-149
https://doi.org/10.1186/1472-6963-14-149...
).

It is also important to have feedback from professionals in the hospital for pre-hospital professionals, because, when they are aware of the patient’s outcome, there may be learning points(2222 Leijen-zeelenberg JEV. Barriers to implementation of a redesign of information transfer and feedback in acute care: results from a multiple case study. BMC Health Serv Res. 2014;3;14:149. doi: 10.1186/1472-6963-14-149
https://doi.org/10.1186/1472-6963-14-149...
), but, for that, it is necessary a training enabling the professionals to follow models and techniques to receive such information.

As a form of intervention to try to make the communication process, in this scenario, have a positive impact on the transfer of a case, since time is restricted and the need for interventions is immediate, it is proposed that the data flow be structured, standardized(1616 Sanjuan A. Handover of patients from prehospital emergency services to emergency departments: a qualitative analysis based on experiences of nurses. J Nurs Care Qual. 2018;34(2):169-74. doi: 10.1097/NCQ. 0000000000000351
https://doi.org/10.1097/NCQ. 00000000000...
,1919 Glind IVD. A national research agenda for pre-hospital emergency medical services in the Netherlands: a Delphi-study. Scand J Trauma ResuscEmerg Med. 2016;24: 2. doi: 10.1186/s13049-015-0195-y
https://doi.org/10.1186/s13049-015-0195-...
,3030 Azevedo ALCS, Pereira AP, Lemos C, Coelho MF, Chaves LDP. Organização de serviços de emergência hospitalar: uma revisão integrativa de pesquisas. Rev Eletron Enferm. 2010;12(4):736-45. doi: 10.5216/ree.v12i4.6585
https://doi.org/10.5216/ree.v12i4.6585...
) and integrated with the team(1515 Hovenkamp GT. The satisfaction regarding handovers between ambulance and emergency department nurses: an observational study. Scand J Trauma ResuscEmerg Med. 2018;10;26(1):78. doi: 10.1186/s13049-018-0545-7
https://doi.org/10.1186/s13049-018-0545-...

16 Sanjuan A. Handover of patients from prehospital emergency services to emergency departments: a qualitative analysis based on experiences of nurses. J Nurs Care Qual. 2018;34(2):169-74. doi: 10.1097/NCQ. 0000000000000351
https://doi.org/10.1097/NCQ. 00000000000...

17 Kalyani MN, Fereidoun Z, Sarvestani RS, Shirazi ZH, Taghinezhad A. Perspectives of patient handover among paramedics and emergency department members; a qualitative study. Emerg (Tehran) [Internet]. 2017 [2019 Jun 06];5(1):e76. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5703753/
https://www.ncbi.nlm.nih.gov/pmc/article...

18 Flynn D, Francis R, Robalino S, Lally J, Snooks H, Rodgers H, et al. A review of enhanced paramedic roles during and after hospital handover of stroke, myocardial infarction and trauma patients. BMC Emerg Med. 2017;17(1):5. doi: 10.1186 / s12873-017-0118-5
https://doi.org/10.1186 / s12873-017-011...

19 Glind IVD. A national research agenda for pre-hospital emergency medical services in the Netherlands: a Delphi-study. Scand J Trauma ResuscEmerg Med. 2016;24: 2. doi: 10.1186/s13049-015-0195-y
https://doi.org/10.1186/s13049-015-0195-...

20 Sujan MA. Emergency Care Handover (ECHO study) across care boundaries: the need for joint decision making and consideration of psychosocial history. Emerg Med J. 2015;32(2):112-8. doi: 10.1136/emermed-2013-202977
https://doi.org/10.1136/emermed-2013-202...
-2121 Sujan MA. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy. 2014;20(1-Suppl):17-25. doi: 10.1177/1355819614560449
https://doi.org/10.1177/1355819614560449...
,3030 Azevedo ALCS, Pereira AP, Lemos C, Coelho MF, Chaves LDP. Organização de serviços de emergência hospitalar: uma revisão integrativa de pesquisas. Rev Eletron Enferm. 2010;12(4):736-45. doi: 10.5216/ree.v12i4.6585
https://doi.org/10.5216/ree.v12i4.6585...
).

Concerning the discrepancy of information between the patient’s real state and that informed before their arrival, it could be avoided with the adoption of electronic data transmission, which would possibly also improve transcription errors as well as communication failures when information is passed on multiple times or when the environment is subject to noise interference(1515 Hovenkamp GT. The satisfaction regarding handovers between ambulance and emergency department nurses: an observational study. Scand J Trauma ResuscEmerg Med. 2018;10;26(1):78. doi: 10.1186/s13049-018-0545-7
https://doi.org/10.1186/s13049-018-0545-...
).

Despite the importance of communication and all the impact on health services, this is a topic that is rarely addressed when it comes to communication in emergency medical services(1919 Glind IVD. A national research agenda for pre-hospital emergency medical services in the Netherlands: a Delphi-study. Scand J Trauma ResuscEmerg Med. 2016;24: 2. doi: 10.1186/s13049-015-0195-y
https://doi.org/10.1186/s13049-015-0195-...
,2424 Evans SM, Murray A, Patrick I, Fitzgerald M, Smith S, Cameron P. Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members. Qual Saf Health Care. 2010;19(6):e57. doi: 10.1136/qshc.2009.039073.
https://doi.org/10.1136/qshc.2009.039073...
). Regarding research on the subject, there is a knowledge gap, confirmed in the findings of another study according to which, in research with 62 specialists in the field of emergency medical services, transferring the patient’s case is one of the priorities of future research(1919 Glind IVD. A national research agenda for pre-hospital emergency medical services in the Netherlands: a Delphi-study. Scand J Trauma ResuscEmerg Med. 2016;24: 2. doi: 10.1186/s13049-015-0195-y
https://doi.org/10.1186/s13049-015-0195-...
,2222 Leijen-zeelenberg JEV. Barriers to implementation of a redesign of information transfer and feedback in acute care: results from a multiple case study. BMC Health Serv Res. 2014;3;14:149. doi: 10.1186/1472-6963-14-149
https://doi.org/10.1186/1472-6963-14-149...

23 Knutsen GO, Fredriksen K. Usage of documented pre-hospital observations in secondary care: a questionnaire study and retrospective comparison of records. Scand J Trauma Resusc Emerg Med. 2013; 1;21:13. doi: 10.1186/1757-7241-21-13
https://doi.org/10.1186/1757-7241-21-13...
-2424 Evans SM, Murray A, Patrick I, Fitzgerald M, Smith S, Cameron P. Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members. Qual Saf Health Care. 2010;19(6):e57. doi: 10.1136/qshc.2009.039073.
https://doi.org/10.1136/qshc.2009.039073...
).

Study limitation

The study has the limitation that the consultation was made in databases in the area of Health and Nursing. The inclusion of other databases may expand the scope of analysis of the communication process of transferring cases from pre-hospital to in-hospital services. In addition, it should be noted that, during the review process, no studies were found in the national territory, which limits an analysis of the Brazilian reality.

Contributions to the Health area

This study discloses some protocols that can collaborate to transfer the case closer to the real need of the patient and, thus, ensure adequate health care. It also contributes to the identification of barriers to this communication process, so that one can intervene early to avoid errors and incidents. In this sense, there is a need for further studies in the area to encourage the exercise of health professionals.

CONCLUSIONS

Transferring a patient’s case is a dynamic, complex and poorly studied process, especially when thinking about the Brazilian reality. Several problems faced by pre-hospital and in-hospital teams can be perceived, from the loss of important information to structural and organizational problems.

In general, studies show the need to standardize the case transfer process, as well as integrative training of professionals and regular assessment of the teams involved in emergency medical services. This study is expected to provide support for future research.

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    » https://doi.org/10.1186/1472-6963-14-149
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    » https://doi.org/10.1590/1981-22562018021.170144
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    Hovenkamp GT, Olgers TJ, Wortel RR, Noltes ME, Dercksen B, TerMaaten JC. The satisfaction regarding handovers between ambulance and emergency department nurses: an observational study. Scand J Trauma Resusc Emerg Med. 2018;26(1):78. doi: 10.1186/s13049-018-0545-7.
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Edited by

EDITOR IN CHIEF: Dulce Barbosa
ASSOCIATE EDITOR: Alexandre Balsanelli

Publication Dates

  • Publication in this collection
    21 Dec 2020
  • Date of issue
    2020

History

  • Received
    19 Nov 2019
  • Accepted
    24 May 2020
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