Patient Handover Research Articles

Evaluation of emergency service nurses' patient handover and affecting factors: A descriptive study

AimThe aim of the study was to determine the patient handover efficacy level of emergency room nurses and the influencing factors. MethodThis descriptive, cross-sectional study was completed with (n = 120) emergency room nurses of two different state hospitals from April 26 to May 26, 2021. The “Nurses descriptive information form” and “Handover Evaluation Scale” were used as data collection forms. ResultsThe mean age of the nurses was 29.53(6.327 years, 70.8% of them were female, and 76.7% of them had a bachelor’s degree. The mean number of handovers was 3.25 (SD = 3.17) for one nurse in a shift, and the mean handover duration for a patient was 10.16 (SD = 9.23) minutes. More than half of the nurses (61.7%) carried out oral handover at the bedside. The mean score of the handover evaluation scale was 53.31 (SD = 9.55). The mean score of the nurses who performed the handover with all the nurses on the shift (spelling and relieving) together was 56.47 (SD = 9.21) and higher than that of the nurses who performed the handover in small groups 49.84 (SD = 9.70), (p = 0.012). ConclusionThe results of this study may contribute to promoting patient safety and improving patient handover processes in emergency rooms. It is recommended that standardized and comprehensive written handover forms be used, that all emergency room nurses should attend the handover process, and that further observational and interventional studies should be conducted.

HUBUNGAN CARING PERAWAT TERHADAP PELAKSANAAN KOMUNIKASI SBAR PADA SAAT HAND OVER

The gap that occurs at the time of handover of the patient is due to incomplete communication so that it can cause disruption in the continuity of nursing which has the potential to endanger the patient. The implementation of patient handover (handover) basically transfers care information and responsibilities from one nurse to another (between shifts) of nurses so that they can provide safe and quality care. This study aims to determine the relationship between nurse caring on the implementation of SBAR communication during hand over cardiac patients in the cardiovascular inpatient ward at Royal Prima Hospital. The research design is descriptive analytic with a cross-sectional approach. This research was conducted in October 2021. The sample in this study were all 32 nurses who served in the cardiovascular inpatient ward. The results of the chi-square test obtained a value of p <0.002, meaning that there is a relationship between nurse caring on the implementation of SBAR communication during hand over cardiac patients in the cardiovascular inpatient ward. It is hoped that respondents can add insight into nurse caring for the implementation of SBAR communication during hand over of cardiac patients in the cardiovascular inpatient ward.

Balanced Opioid Prescribing via a Clinical Trade-Off: Pain Relief vs. Adverse Effects of Discomfort, Dependence, and Tolerance/Hypersensitivity

In the backdrop of the opioid epidemic, opioid prescribing has distinct medical and social challenges. Overprescribing contributes to the ongoing opioid epidemic, whereas underprescribing yields inadequate pain relief. Moreover, opioids have serious adverse effects including tolerance and increased sensitivity to pain, paradoxically inducing more pain. Prescribing trade-offs are recognized but not modeled in the literature. We study the prescribing decisions for chronic, acute, and persistent pain types to minimize the cumulative pain that incorporates opioid adverse effects (discomfort and dependence) and the risk of tolerance or hypersensitivity (THS) developed with opioid use. After finding closed-form solutions for each pain type, we analytically investigate the sensitivity of acute pain prescriptions and examine policies on incorporation of THS, patient handover, and adaptive treatments. Our analyses show that the role of adverse effects in prescribing decisions is as critical as that of the pain level. Interestingly, we find that the optimal prescription duration is not necessarily increasing with the recovery time. We show that not incorporating THS or information curtailment at patient handovers leads to overprescribing that can be mitigated by adaptive treatments. Last, using real-life pain and opioid use data from two sources, we estimate THS parameters and discuss the proximity of our model to clinical practice. This paper has a pain management framework that leads to tractable models. These models can potentially support balanced opioid prescribing after their validation in a clinical setting. Then, they can be helpful to policy makers in assessment of prescription policies and of the controversy around over- and underprescribing. History: This paper has been accepted for the Decision Analysis Special Issue on Emerging Topics in Health Decision Analysis. Funding: This work was supported by the National Institutes of Health [Grants K08 EB022631, R24 DA055306, R33 DA046085, and U24 NS115708]. Supplemental Material: The online appendix is available at https://doi.org/10.1287/deca.2021.0447 .

Abstract WP95: Acute Stroke Simulation Training For General Medical Trainees: Busting Clots, Myths And Fears

Background: Acute stroke assessment and management is a time critical process. The emergency “stroke call” should include a standardised NIHSS assessment, initial observations and investigations and a decision regarding thrombolysis and thrombectomy. We found this to be daunting for trainees, and it has been documented that physician experience impacts upon door-to-needle time. Aims: The aim of our simulation training was to provide a safe environment to improve the ability and confidence of trainees in leading stroke calls with a view to improving acute stroke care and patient access to revascularization therapies. Method: We designed a one-day simulation course aimed at internal medicine trainees who are expected to lead stroke calls currently or in the immediate future. The candidates are surveyed to establish baseline confidence and complete questionnaires to assess knowledge about managing acute strokes. Here we present data from the first 18 attendees. The course is led by stroke consultants, assisted by members of the multidisciplinary team, including medical trainees, stroke specialist nurses and a paramedic. Alongside structured seminars, simulated acute stroke scenarios lead each candidate through patient handover, assessment, investigation and management decisions followed by a structured debrief. Clinical results, equipment and live monitoring are used to increase the fidelity of the simulation. Results: The course improved candidates' confidence in leading a thrombolysis call from a mean of 2.83/10 to 7.11/10, found to be statistically significant on Paired T-Test(t=9.69, p=<0.0001). Furthermore, the candidates’ acute stroke management quiz scores rose from a mean of 5.67/10 to 8.17/10 (t=5.28, p=<0.0001). Qualitative feedback included: “Good broad interactive session on a subject we get limited teaching on” and “Fantastic, clinically relevant course. I feel much more confident to attend thrombolysis calls now”. Conclusions: Simulation is an established staple of acute medical education, and has a demonstrable benefit when applied to acute stroke management training. We propose that this opportunity should be widely available if not mandatory to internal medical training.

Optimizing handover in patients with stroke symptoms utilizing an organized protocol between emergency department providers and emergency medical personnel

IntroductionStroke care is time sensitive. Providers in the emergency department (ED) depend on advanced notification from emergency medical services (EMS) transporting patients with stroke signs and symptoms. Barriers to EMS-ED information transfer can delay patient arrival preparation that may impact decisions, diagnosis, and time-sensitive transfer to next site of care. Information gaps or loss of information in the chain of care has been noted to contribute to possible safety threats for patients with stroke symptoms. MethodsThe aim of this project was to explore the feasibility of improving EMS-ED handover of patients with suspected stroke using a two-tiered checklist ranked in order of importance and a “time-out” upon EMS arrival to help standardize report, bridge the information gap, and promote earlier stroke management decisions. Paramedics from two local EMS agencies participated. Transmission and recorded report were measured before and after implementation followed by a satisfaction survey. Analysis also included a comparison group (control) of non-participating Fire Departments. ResultsOne hundred and sixty-eight potential stroke patients were transported to the ED during the 16-month intervention time frame. The pre and post intervention analysis of reported stroke symptoms showed statistically significant improvement in multiple checklist reporting areas. Noteworthy changes included improvement in reporting last time normal, current antiplatelet/anticoagulant, neurological deficits, baseline mental and functional status, medical history, code status, recent surgical history and family enroute. A post-survey demonstrated overall positive EMS-ED response to the new handover process. ConclusionThe feasibility of an EMS-ED standardized handover using a hierarchical (ranked in order of importance), two-tiered checklist and time-out process can effectively bridge the gap of communication between EMS and emergency providers to help promote timely hyperacute stroke care.

Assessing the quality of patient handovers between ambulance services and emergency department \u2013 development and validation of the emergency department human factors in handover tool

BackgroundPatient handover between prehospital care and the emergency department plays a key role in patient safety. Therefore, we aimed to create a validated tool for measuring quality of communication and interprofessional relations during handover in this specific setting.MethodsBased on a theoretical framework a comprehensive item pool on information transfer and human factors in emergency department handovers was created and refined in a modified Delphi survey involving clinical experts. Based on a pre-test, items were again revised. The resulting Emergency Department Human Factors in Handover tool (ED-HFH) was validated in a field test at the emergency department of a German university hospital from July to December 2017. The ED-HFH was completed by emergency department and ambulance service staff participating in handovers and by an external observer. Description of item characteristics, exploratory factor analysis, analyses on internal consistency and interrater reliability by intraclass-correlation. Construct validity was analysed by correlation with an overall rating on quality of the handover.ResultsThe draft of the ED-HFH contained 24 items, 90 of 102 eligible staff members participated in the field test completing 133 questionnaires on 38 observed handovers. Four items were deleted after analysis of item characteristics. Factor analysis supported a single factor explaining 39% of variance in the items. Therefore, a sum-score was calculated with a possible range between 14 and 70. The median value of the sum-score in the sample was 61.5, Cronbach’s α was 0.83, intraclass-correlation was 0.52, the correlation with the overall rating of hand-over quality was ρ = 0.83 (p ≤ 0.001).ConclusionsThe ED-HFH showed its feasibility, reliability and validity as a measure of quality of information transfer and human factors in handovers between ambulance services and the emergency department. It promises to be a useful tool for quality assurance and staff training.

Experiences of healthcare providers with a novel emergency response intubation team during COVID-19.

ObjectivesIn the early stages of the COVID-19 pandemic, there were significant concerns about the infectious risks of intubation to healthcare providers. In response, a dedicated emergency response intubation team (ERIT) consisting of anesthesiologists and allied health providers was instituted for our emergency department (ED). Given the high-risk nature of intubations and the new interprofessional team dynamics, we sought to assess health-care provider experiences and potential areas of improvement.MethodsSurveys were distributed to healthcare providers at the University Health Network, a quaternary healthcare centre in Toronto, Canada, which includes two urban EDs seeing over 128,000 patients per year. Participants included ED physicians and nurses, anesthesiologists, anesthesia assistants, and operating room nurses. The survey included free-text questions. Responses underwent thematic analysis using grounded theory and were independently coded by two authors to generate descriptive themes. Discrepancies were resolved with a third author. Descriptive themes were distilled through an inductive, iterative process until fewer main themes emerged.ResultsA total of 178 surveys were collected (68.2% response rate). Of these, 123 (69%) participated in one or more ERIT activations. Positive aspects included increased numbers of staff to assist, increased intubation expertise, improved safety, and good team dynamics within the ERIT team. Challenges included a loss of scope (primarily ED physicians and nurses) and unfamiliar workflows, perceived delays to ERIT team arrival or patient intubation, role confusion, handover concerns, and communication challenges between ED and ERIT teams. Perceived opportunities for improvement included interprofessional training, developing clear guidelines on activation, inter-team role clarification, and guidelines on handover processes post-intubation.ConclusionsHealthcare providers perceived that a novel interprofessional collaboration for intubations of COVID-19 patients presented both benefits and challenges. Opportunities for improvement centred around interprofessional training, shared decision making between teams, and structured handoff processes.

Continuing Education of Nurses in Patient Handovers: Development and Evaluation of a Digitally Enabled Problem-Based Learning Course.

Communication deficits belong to the most frequent errors in patient handovers calling upon specialized training approaches to be implemented. This study aims to harness problem-based learning (PBL) methods in handover education and evaluated the learning process. A digitally enabled PBL course was developed and implemented at Klinikum Osnabrück from which eight nurses participated in the course. They agreed on the stimulating effect of the setting regarding self-directed learning and on the potential to translate the new knowledge and skills into the daily clinical practice. In conclusion, the findings are promising that a digitally enabled PBL course is a suitable learning format for handover education.

A GIS Tool That Provides Intelligent Solutions in Emergency Departments during COVID-19

The response to the COVID-19 pandemic has led to a revolution in open geographic information system (GIS) sources and Web GIS, which have grown considerably. Patient handover and crowding are critical issues to address during the COVID-19 pandemic. Saudi Arabia’s Vision 2030 aims to optimise quality and resource utilisation in emergency departments (EDs). GIS technology has been used to clarify the state of COVID-19 at the country level, however, the potential of GIS technology requires ongoing investigation to support Saudi Arabia’s Vision 2030. During a pandemic, great pressure is placed on EDs, with patients waiting long periods for treatment, which can lead to great health risks. This paper aims to illustrate the rule of GIS in providing intelligent solutions in emergency services during the COVID-19 pandemic. A satisfaction questionnaire was distributed to over 180 patients who were selected randomly from the nine emergency rooms of Jeddah governorate hospitals from different priority levels. Fifteen factors are determined and grouped into five domains to reflect patients’ satisfaction: emergency department environment, emergency department staff, physician care satisfaction, and wait time satisfaction. The critical values reveal in wait time were 84% of patients from the second to the fourth level of priority had waited a long or extremely. Most of the respondents (87%) wanted to know ER wait times before arrival hospital. The website was the most preferred choice for publishing wait times outside the ER for 56.7% of them. An online ArcGIS dashboard was developed to monitor hospital wait times in Jeddah City. This dashboard can be useful to the public to guide them in determining which hospital is the most suitable regarding a minimum waiting time and can also help in considering the travel distance.

Developing Nursing Standards for Maintaining Shift Handover in the Intensive Care Unit: A Methodological and Cross-Sectional Study.

Patient handover, which is a method of moving the clinical data of patients to another individual or professional community, is a high-risk area for the safety of patients due to errors which can happen during staff break time, changeover shifts, and when patients are moved in and out of units. Standards for critical care nurses will improve bedside handover due to the presence of clear plans implemented by nurses who are well informed about them. To develop nursing standards for maintaining handover in the intensive care unit. A methodological and cross-sectional study was conducted at Mansoura University Hospital and included 15 experts and 150 staff nurses. Twelve items were excluded from the tool because their CVR ratio was less than 0.7. Therefore, after eliminating 12 items, the number of tool items produced was 66. The Kaiser-Meyer-Olkin value = 0.713, with the recommended value being 0.6 or above. The cut-off score for the analysis model was 0.3, and the KMO value criterion was greater than 1, which defined eight-factor loadings as the best fit for the results, accounting for 69.5% of the variance. The aim of this study was satisfactorily achieved, with 0.9055 validity and reliability for the handover instrument, which consisted of 60 items with a total reliability score.

Improving the handover of complex trauma patients by implementing a standardised process

Introduction: Clinical handover continues to be a safety priority. The transfer of complex trauma patients presents additional challenges. Utilising a standardised process may be valuable in improving patient transfer.

Development of An Electronic Referral Proforma from Paramedics to General Practitioners: A Delphi Study

Introduction Currently, non-transported patients who are attended to by a state-funded ambulance service in Victoria and are advised to visit their general practitioner (GP) do not have informational continuity of care, as there is no communication between the referring paramedic and GP. This research aimed to develop a functional electronic referral (e-referral) proforma from paramedics to GPs that can be used to support handover of patients’ clinical information for non-transported patients. Methods Paramedics, GPs and digital health experts were invited to participate in the study. The study design utilised an online Delphi technique, where participants responded to three rounds of surveys relating to the pertinence, feasibility, content and presentation of an e-referral tool. Questions were open-ended or requested responses on a 5-point Likert scale. Results A total of 21 clinicians participated in the study and developed an e-referral proforma. After three rounds, participants agreed the proforma should contain the following information: the patients’ identifying information, presenting complaint, social concerns, vital sign survey, management or advice given to the patient and reason for referral. Stakeholders stressed that the mode and timing of delivery must be flexible enough so that implementing the e-referral proforma does not become burdensome for clinicians. Conclusion A structured e-referral system between paramedics and GPs is feasible and offers a method to improve informational continuity of care and in turn, patient safety.

Using an Early Warning Score for Nurse Shift Patient Handover: Before-and-after Study

PurposeThis study aimed to examine the impact of using an early warning score for shift patient handover on nurse and patient outcomes. MethodsA before-and-after study was conducted with nurses and patients in three general wards in a tertiary teaching hospital. A short-time nurse education on the National Early Warning Score 2 and the use of a checklist for score calculation were performed from June 4, 2019 to June 30, 2019. Outcomes of nurse response (safety competency, handover quality, teamwork, safety climate, and documentation of vital signs and clinical concerns), patient response (deterioration occurrence postadmission, hospitalization length, and discharge status), and adverse events (mortality, cardiopulmonary arrest, and unplanned intensive care unit admission) were measured using questionnaires and medical record reviews. Data from 89 nurses and 388 patients were analyzed. ResultsRegarding nurse outcomes, handover quality (p < .001), teamwork (p = .004), safety climate (p = .018), and recordings of vital signs (p = .047) and clinical concerns (p = .008) increased after early warning score use. However, no significant change in the safety competency scores was observed. Regarding patient outcomes, there were no significant changes in the occurrence of deterioration, hospitalization length, discharge status, and occurrence of adverse events between preintervention and postintervention. ConclusionDespite no significant changes in patient outcomes, using a simple, evidence-based early warning score for patient handover enhanced socio-cultural factors for patient safety, with improved patient monitoring. The findings provide evidence that supports the active implementation of an early warning score to improve patient safety.

155 Piloting a Tabletop Simulation to Prepare Nurses for Ward Coordination

We know staff attrition is a core challenge for the NHS with many nurses leaving the profession in the first 2 years post-qualification The aim of the study was to improve retention and resilience of the nursing workforce by increasing confidence in their ability at clinical coordination.This table-top simulation pilot used a convenience sample of six staff nurses new to the role of clinical coordinator. We drew on clinical governance findings and input from experienced nurse-coordinators to simulate coordinating a shift on a surgical emergency unit. The shift was run in compressed time over 32 minutes followed by a 1.5 hour debrief. During the shift we used ‘injects’ intentionally designed to stimulate learning in: Problem solvingDecision-makingClinical processesSupporting colleagues/workforce resilienceSituational awarenessThe pilot was evaluated through peer observation and focus group. Peer observation provided an objective analysis of session content. A neutral party facilitated the focus group, which gathered data on how the training session had been received by participants and evaluated whether learning outcomes were met by content.Participants were assigned to work in pairs. Briefing was provided for session content and timeline. We used a simulated handover of patients for verisimilitude. The 12-hour shift was compressed into 4-minute segments with a ‘countdown’ timer ticking off each segment as the simulated shift progressed. This added time pressure and demonstrated how decision-making skills can be influenced by external forces. The participants had access to the hospital intranet and documented their actions/decisions on a template. Facilitated discussion took place after the tabletop simulation followed by a lunch break and then the focus group.

Handover of Critical Patients in Urgent Care and Emergency Settings: A Systematic Review of Validated Assessment Tools.

The emergency handover of critical patients is used to describe the moment when responsibility for the care of a patient is transferred from one critical patient care healthcare team to another, requiring the accurate delivery of information. However, the literature provides few validated assessment tools for the transfer of critical patients in urgent care and emergency settings. To identify the available evaluation tools that assess the handover of critical patients in urgent and emergency care settings in addition to evaluations of their psychometric properties, a systematic review was carried out using PubMed, Scopus, Cinahl, Web of Science (WoS), and PsycINFO, in accordance with PRISMA guidelines. The quality of the studies was assessed using the COSMIN checklist. Finally, eight articles were identified, of which only three included validated tools for evaluating the handover of critical patients in emergency care. Content validity, construct validity, and internal consistency were the most studied psychometric properties. Three studies evaluated error and reliability, criterion validity, hypothesis testing, and sensitivity. None of them considered cross-cultural adaptation or the translation process. This systematic psychometric review shows the existing ambiguities in the handover of critically ill patients and the scarcity of validated evaluation tools. For all of these reasons, we consider it necessary to further investigate urgent care and emergency handover settings through the design and validation of an assessment tool.

A Study of Cloud-Based Remote Clinical Care Technology.

This paper uses cloud computing to build and design remote clinical care technology, and the study refines the evaluation approach for the elements and builds an evaluation prototype for the strategy, uses service design theory to improve the design of the service part of the assistive system, summarizes the list of requirements based on system design and service design, and designs a service design prototype. Through design practice, the detailed design of the software interaction interface and the auxiliary product of the care assistance system based on the prototype are investigated. Based on the user perspective, the strategy of meeting user expectations and improving user information literacy is proposed; based on the social network perspective, the strategy of establishing a long-term mechanism for smart medical operation and improving the information interaction network environment is proposed; and based on the system service perspective, the strategy of optimizing the system function design and innovating the service model is proposed. Compared with the traditional written patient handover, the application of MNIS under cloud computing can significantly shorten the handover time of surgical patients, improve the standardized rate of surgical safety verification execution and the qualified rate of nursing documents, while the rate of standardized application of prophylactic antibiotics is also significantly higher than that of the control group. The questionnaire survey of nursing staff in the operating room showed that clinical nursing staff was generally satisfied with the clinical application of MNIS under cloud computing, with an average satisfaction score of 64.5 to 11.3, and an average score of 3.58 to 0.54 for each item. Among them, pre-application training of MNIS, departmental support for MNIS, and its ease of verification in surgical patients were the three main factors favoring the clinical application of MNIS in the operating room with cloud computing, while barriers to wireless network connectivity, inconvenient PDA input, and small screen size were the three main drawbacks affecting its application. The determined clinical evaluation index system of MNIS in the operating room is innovative, which not only includes clinical care indicators but also covers general hardware and software indicators, which can effectively reflect the practical application capability of mobile terminal clinical and user experience feelings, and the evaluation index system is comprehensive.

A systematic review of ePCR systems on reducing the response time of prehospital medical care

Background Poor communication at the time of patient handover is recognized as a root cause of a considerable proportion of preventable deaths. Despite several advantages, the Patient Care Report (PCR) implementation may include insufficient details for demonstrating the functional status of the patients during the actual response which can further prolong the response time. Healthcare entities have been emphasizing the need to implement e-PCR systems. This systematic review aimed to examine the impact of e-PCR systems on reducing response time of prehospital care. Methods Literature search was carried out using the relevant search terms and keywords with inclusion and exclusion criteria. N=6 researchers that focused on the impact of e-PCR systems on reducing response time of prehospital medical care were included within this review. Results The findings indicated that ePCR implementation led to prominent improvements in the quality of the care services provided by the healthcare organisation. Additionally, ePCR reduces the response rate by data standardization. Conclusion The implementation of e-PCR systems ensures the availability of records and automates reporting on given quality metrics. Moreover, the implementation of e-PCR systems also improved response time and increased the out of hospital rates of survival. However, fear of increasing the ambulance run time, compromise on the availability of ambulance, and challenges in integration with the existing information systems implemented within the hospitals, were some of the most common challenging situations associated with implementing e-PCR systems.

ISBAR as a Structured Tool for Patient Handover During Postoperative Recovery

PurposeThe purpose of this study was to investigate interaction in the handovers between anesthesia and the recovery room and to examine the effect of using the Identification, Situation, Background, Analysis, and Recommendation (ISBAR) instrument as a structured dialogue tool during hand over. DesignA prospective quality improvement project with pre/post assessment. MethodsFifty handovers in the postanaesthesia care unit were observed. Data were collected regarding parameters associated with ISBAR. Both certified registered nurse anesthetists and registered nurses (RNs) from postanaesthesia care unit were subsequently asked about their satisfaction with the handover via an electronic questionnaire survey. After 6 months, the questionnaire survey was repeated, and 50 observations were conducted identical to the baseline observations. FindingsResults showed that from baseline to follow-up, RNs were more prepared to receive the patient (from 84% to 95%), read the patient records more frequently (from 18% to 54%), and were assigned to patients from the start of the day (from 86% to 100%). The content of the oral handover was more structured using the ISBAR, and handovers became more concentrated and undisturbed (from 12% to 86%). At baseline, certified registered nurse anesthetists were more satisfied with the handover than RNs (38% difference). At the follow-up, there was no discrepancy between the two groups. ConclusionsKnowledge and focus on the verbal handover influence communication, team effectiveness, and quality of handovers. The ISBAR structured approach reduced disturbances to handover because everybody involved had a clear expectation of the different items to be reviewed and were less likely to interrupt to question or clarify. Using ISBAR as a structured tool along with organizational changes can improve the quality of patient handover and thereby improve patient safety.

"Friction by Definition": Conflict at Patient Handover Between Emergency and Internal Medicine Physicians at an Academic Medical Center.

IntroductionPatient handoffs from emergency physicians (EP) to internal medicine (IM) physicians may be complicated by conflict with the potential for adverse outcomes. The objective of this study was to identify the specific types of, and contributors to, conflict between EPs and IM physicians in this context.MethodsWe performed a qualitative focus group study using a constructivist grounded theory approach involving emergency medicine (EM) and IM residents and faculty at a large academic medical center. Focus groups assessed perspectives and experiences of EP/IM physician interactions related to patient handoffs. We interpreted data with the matrix analytic method.ResultsFrom May to December 2019, 24 residents (IM = 11, EM = 13) and 11 faculty (IM = 6, EM = 5) from the two departments participated in eight focus groups and two interviews. Two key themes emerged: 1) disagreements about disposition (ie, whether a patient needed to be admitted, should go to an intensive care unit, or required additional testing before transfer to the floor); and 2) contextual factors (ie, the request to discuss an admission being a primer for conflict; lack of knowledge of the other person and their workflow; high clinical workload and volume; and different interdepartmental perspectives on the benefits of a rapid emergency department workflow).ConclusionsCauses of conflict at patient handover between EPs and IM physicians are related primarily to disposition concerns and contextual factors. Using theoretical models of task, process, and relationship conflict, we suggest recommendations to improve the EM/IM interaction to potentially reduce conflict and advance patient care.

Using the South African Triage Scale for prehospital triage: a qualitative study

BackgroundTriage is a critical component of prehospital emergency care. Effective triage of patients allows them to receive appropriate care and to judiciously use personnel and hospital resources. In many low-resource settings prehospital triage serves an additional role of determining the level of destination facility. In South Africa, the Western Cape Government innovatively implemented the South African Triage Scale (SATS) in the public Emergency Medical Services (EMS) service in 2012. The prehospital provider perspectives and experiences of using SATS in the field have not been previously studied.MethodsIn this qualitative study, focus group discussions with cohorts of basic, intermediate and advanced life support prehospital providers were conducted and transcribed. A content analysis using an inductive approach was used to code transcripts and identify themes.Results15 EMS providers participated in three focus group discussions. Data saturation was reached and four major themes emerged from the qualitative analysis: Implementation and use of SATS; Effectiveness of SATS; Limitations of the discriminator; and Special EMS considerations. Participants overall felt that SATS was easy to use and allowed improved communication with hospital providers during patient handover. Participants, however, described many clinical cases when their clinical gestalt triaged the patient to a different clinical acuity than generated by SATS. Additionally, they stated many clinical discriminators were too subjective to effectively apply or covered too broad a range of clinical severity (e.g., ingestions). Participants provided examples of how the prehospital environment presents additional challenges to using SATS such as changing patient clinical conditions, transport times and social needs of patients.ConclusionsOverall, participants felt that SATS was an effective tool in prehospital emergency care. However, they described many clinical scenarios where SATS was in conflict with their own assessment, the clinical care needs of the patient or the available prehospital and hospital resources. Many of the identified challenges to using SATS in the prehospital environment could be improved with small changes to SATS and provider re-training.