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Transfer of Care Concerns?

Discussion in 'BLS Discussion' started by TomTheEMT, Feb 8, 2018.

  1. TomTheEMT

    TomTheEMT Forum Ride Along

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    Whether you respond to a nursing home for an emergency or you're giving your report in the emergency room at the hospital, you're interacting with nurses & staff. Do you feel like these conversations are not as effective as they can be? Do you and your partner have to pry information out of a nurse who seems almost annoyed with the fact that you're asking basic questions any other trained EMT would ask? Do you feel like your report in the emergency room isn't taken as seriously as it should be sometimes? Patients need an advocate- don't get lost in the frustration and forget that sometimes we're the voice that these people don't have.
    Just interested to hear if anyone can relate to this or not. How do you handle it/what do you need to improve on?
     
    Last edited: Feb 8, 2018
  2. mgr22

    mgr22 Forum Asst. Chief

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    Sure, TomTheEMT, I can relate. I've been on the receiving end of many EMT reports. Hope you don't mind if I play devil's advocate:

    Do you ever find it hard to get information, or even respect, from EMTs whose medical education is a fraction of your own? Do you sense some EMTs think you don't know as much about "real medicine" as they do, because you work in a hospital instead of on an ambulance? Have you ever run across EMTs who expect you to treat them like heroes because they're used to getting props merely for volunteering? Wouldn't it be nice if EMTs knew more about what they don't know?

    Don't get lost in frustration; patients need at least some caregivers with more education than cosmeticians.
     
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  3. EpiEMS

    EpiEMS Forum Deputy Chief

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    Respect is a two-way street.

    More often than not, I think it's because we don't understand each others' constraints...
     
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  4. VentMonkey

    VentMonkey Jefíto Premium Member

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    Til this day Hollywood shows the “ambulance people” dropping off their patients holding a glass vial of NS in one hand above their patient, on an oxygen mask, all while whisking their patient through the lobby of some hospital building. It doesn’t get any more respectful than that:).

    To the OP, eh I think that you’re missing a large piece of the puzzle. Is what you have to tell said hospital staff really so life-changing that they should afford you some grandiose platform?

    One thing I’m happy my area does overall is ask for a report in the “meat and potatoes” fashion. Anything else worth asking that I may not have mentioned can be asked by the staff when we actually do a hand-off.

    I wouldn’t go expecting what I said to have such great bearing on the patient’s care that it made the difference between them living or dying though; that’s nothing short of self-importance.
     
    Last edited: Feb 8, 2018
    EpiEMS likes this.
  5. EpiEMS

    EpiEMS Forum Deputy Chief

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    I think this is generally true for EMS care (considering the vast majority of the calls we have), not just our reporting.

    Of course, there are the exceptions. I can think of...maybe a dozen calls in the past couple years that I've had where my findings and treatments (apart from pure ABC fixes) made a difference.
     
  6. VFlutter

    VFlutter Flight Nurse

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    The ER nurse you are giving report to is usually multitasking trying to get report from you, while listening to the Trauma team shout out assessments and orders that the nurse is responsible for documenting. As well as trying to call the blood bank and lab etc. What you think is important may not be to them. The are going to redo and entire assessment, probably change out your IVs, and treat accordingly. Don't take offense.

    The "patients need an advocate" comment is a little insulting since you are implying the nurse who may not be listening to you how you would like are not capable of being a patient advocate when that is one of their primary jobs that they take very seriously.

    If they are not listening to you that means that the information you are providing probably could be more consice and relevant.

    Having said that even as a flight crew it happens. Be patient, wait for the appropriate time to give information, and keep it short and simple.
     
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  7. TomTheEMT

    TomTheEMT Forum Ride Along

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    I
     
  8. TomTheEMT

    TomTheEMT Forum Ride Along

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    I agree there are people in every line of work who put themselves on a pedestal they aren't deserving of. I'm not sure undermining all EMT's by essentially saying their medical knowledge is a fraction of who they're handing patient care off to is doing any help to this issue. Again, everyone needs to put themselves in each other's shoes. Maybe I didn't make that clear enough. But if a SNF healthcare professional calls a priority 3 for a patient with altered mental status, for example, and you get there to find her say "she's having trouble breathing, she's also a diabetic" and that's the extent of your report, are you happy with that? No vitals taken. We find her BGL to be 409 and her O2 sat 89%. I appreciate that my medical education is considered a "fraction" of that nurse's, however it seemed that us ambulance drivers were able to do a bit more of an assessment for our pt.
     
  9. EpiEMS

    EpiEMS Forum Deputy Chief

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    We don't know their constraints. I am loathe to defend SNFs, considering how bad many of them are, but even at the good ones, the RNs (and LPNs and CNAs) are taking care of multiple times the number of patients we are taking care of...even over a whole shift. We're talking 1 RN to 40 patients, potentially - I take care of 1 at a time (and over the course of a whole shift, 12 or so). Yes, we should expect a good assessment, but I'm not sure that it is practical to expect one.
     
  10. mgr22

    mgr22 Forum Asst. Chief

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    TomTheEMT, I don't doubt you've had bad experiences with other healthcare providers. You may even be right about the reasons for that some of the time. What I'd like you to try and understand, though, is that just as you were put off by my hypothetical generalizations about EMTs, some other healthcare providers will feel your generalizations were unduly negative.

    Also, since you're asking about ways to improve, I'd encourage you, as a self-professed ambulance driver, to begin by doing the best job you can driving ambulances.
     
  11. MedicBender

    MedicBender Forum Captain

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    There seems to be 2 parts to this conversation, and we're drifting in and out of both.

    The first being receiving report from either SNF or whoever called 911 initially. While it's true that SNFs have a reputation for being a little light on information, part of the responsibility also lies in the responding providers to ask the right questions. While it's true that you will get responses like "it's not my patient" or "I don't usually work this ward", some nurses will be able to give you a run down if you ask the right questions. I've found that light questions get light answers. "Why did you call" will result in "she's sick", however probing a bit more and asking for the nurses impression, assessment, and thoughts may get you more information.

    The second part being the report you're handing over at the receiving facility. I've worked ambulance triage in hospital for quite a few years and dealt with thousands of crews. Some reports are straight forward, to the point, and don't waste my time. Other reports are a mixed bag of facts, opinions, irrelevant observations, topped off with a vague chief complaint. To echo what VFlutter said, the nurse receiving your report is probably juggling 40 other tasks. When I take report I don't need a life story. I need to know who they are, a chief complaint, a brief assessment, and anything that is life threatening in the next 15 minutes.

    Have you tried using a platform like SBAR? It can be used for both initial contact and giving report at the hospital. When I hand over, I try to follow this model.
    Situation: Who they are and their main chief complaint
    Background: Medical/Medical/Social/Allergy history. For 99% of patients, this can be one to two sentences.
    Assessment: ABCDE, that's all I need. Recent vitals if the hospital requires them. Again, one to two sentences.
    Recommendation: Your primary impression of the condition, and anything life threatening I need to deal with in the next 15 min.

    This entire report should be as brief as possible. Write it down before you go in so you're not struggling to remember. This same platform can be used when questioning the nurse who called. Most nurses at SNF will feel more appreciated when asked for their impression and recommendation than if you just "Whats up"
     
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  12. DrParasite

    DrParasite The fire extinguisher is not just for show

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    As long as the nursing home has the paperwork ready when I get there, I'm happy. a verbal report from any of the staff is just gravy. And I don't buy the contraints statement, they called us, for an unstable patient that they couldn't handle; give me the paperwork that I need to do my job, and then I will gladly be on my way. 5 minutes of their time will make my job much easier, and then they can go back to the other patients who are stable.

    If I have something important to tell the nurse at the receiving hospital, (IE, something that if they don't know they patient will likely suffer a negative patient outcome), than I will make sure the nurse know it. the rest they can read about in my chart. Believe me, if they want to know something, they will ask you.

    BTW, nurses, especially ER nurses, see maybe 50 EMS crews a day (maybe more in the busy cities).... very often you are simply a means of delivering patients to them. I found most will ignore everything you say until they get to know you, recognize you from giving good reports on sick patients, and actually talk to them like people, because they are, usually, juggling several patients as well as the new one. Don't take it personally, and keep doing your job well.

    and if it doesn't, don't stress it, there are plenty of worse issues to deal with in EMS
     
  13. EpiEMS

    EpiEMS Forum Deputy Chief

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    You're right in the sense that they have a duty to the patient to give us a good report. But I really don't think we can expect the same level of handover from a SNF as we might want. They called us because they couldn't handle it - so I'm not surprised if they're flustered...
     
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  14. DrParasite

    DrParasite The fire extinguisher is not just for show

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    Can we agree to disagree on this one? I don't think it's too unreasonable for one of them to be in the room with the patient treating them (and being ready to give a verbal report) and getting information for us about the patient's acute condition while another staff member is copying the chart. After all, they have 3-10 minutes from the time they call 911 until EMS arrives.

    I don't have an issue with them being flustered, but we all still have a job that needs to get done.
     
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  15. EpiEMS

    EpiEMS Forum Deputy Chief

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    Certainly they should - at least - be trying to treat the patient, and have a chart ready.

    (I'm mainly trying to get the point across to the OP that - and I think you'd agree - different places have different constraints. I probably wasn't really effective in expressing that.)
     
  16. Peak

    Peak ED/Prehospital Registered Nurse

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    If it makes you feel any better, on the ED side I often have to call LTACs and SNFs to try to get even the basics out of the staff (more often I'm unsuccessful). It's not a matter of not being ready for an ambulance or looking down on anyone, many facilities have 20+ patients per LPN and maybe one RN in the whole facility looking after 50-100 patients. These are also not critical care trained nurses and emergent situations are not in their wheelhouse. It isn't fair to expect them to function as an EMT, it is in neither their training nor their experience.

    As far as receiving report for EMS crews, a lot has to depend on how sick the patient is. What you might see as DFO AMS I could see as a septic UTI, and I need to get cultures and start antibiotics as fast as possible, not just for metrics but to make sure the patient has a good outcome. What you see as a 8 YOM who was obtunded and had a CO of 40 on the rad-57 I see as a child who is now interacting and mentating appropriately (mostly because EMS treated his CO with high flow Os and his CO is now 26). What you see as a 18.4 OB bleeding with back pain I see as a mild subchorionic hemorrhage that I discharged 5 hours ago but has extremely low health literacy. What you see as a toddler who is retracting I see a pink/warm/dry child with good tears, moist mucus membranes, behaving appropriate for medical condition and age, cap refill less than 1 second, and has a pectus excavatum that will probably get a nuss bar in a few years, and has a cold.

    There is a chance that the ED staff are rude, I can attest that those nurses and providers certainly do exist. I would suggest that more likely is that said ED staff are trying to assess and stabilize while also listening, which does have the chance of coming off as uncaring. That being said if crews want to come and talk to us later either to give more information or learn about the patient outcome I am always more than willing to talk. I would suggest that you try to have those conversations before you leave the ED, and if you still feel like either you or the patient were not treated appropriately talk to your supervisor or the hospital's EMS coordinator.
     
  17. Remi

    Remi Forum Deputy Chief Premium Member

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    I'm not really sure why the OP's question has drawn some of the responses that it has received here. I think poor transfer-of-care reports is a pretty legit problem and the topic has drawn quite of a bit of attention over the past handful of years from oversight agencies such as the JC. Level of education and respect (or lack of) for the person giving report should have nothing at all to do with it. This is about the patient, not about the person giving or receiving report.

    A big part of the problem - as has been illustrated in some of the replies here - is that we all (SNF personnel, EMS personal, ED nurses) have different perspectives and priorities when it comes to patient care. That fact does nothing but underscore the importance of some sort of standard protocol for transferring information from one care provider to another.

    A nurse in a nursing home might have literally dozens of patients in her charge. They are all old, they are all sick, and they all have multiple medical problems. The focus when caring for these patients is not on figuring out what is wrong with them and how to fix it; it is generally accepted that these patients are dying and the priority is generally on managing their current health problems in a way that keeps them comfortable. This is why at any given time, if a paramedic were to assess every patient in a SNF, by protocol at least half of them would probably earn a L&S ride to the closest ED. But in reality, being old and sick isn't necessarily an emergency. So when you ask a SNF RN pointed questions about a patient's history and the onset of their symptoms, the fact that they can't answer doesn't make them an idiot. In some cases they don't even know that the patient's physician arranged for a transfer to hospital until you were dispatched. You take charge of 25 bedridden, demented patients with numerous medical problems and deal with all their families and doctors and ancillary services and mountains of paperwork and the 10 CNA's and LPN's working for you and then when I show up tell me exactly when their difficulty breathing started and what year their last stroke was and what their most recent lab values were and everything about their history that I might want to know. Not as easy as it sounds.

    As an EMT, we are trained to focus all our attention on one patient, and that everything is an emergency, and information must be gathered quickly in order to make life-altering decisions. Almost the perfect opposite of what long-term care staff do. No wonder we have a hard time relating and communicating.

    In the ED, staff have to sort patients by "sick / not sick" quickly and again, what EMS personnel are taught is "sick" isn't necessarily so, relative to what shows up at the ED. A paramedic or EMT in a busy urban system might see 10 patients in a shift. The triage nurse in a busy ED might see twice that per hour hour over an 8 or 12 hour shift. I'll be the first to admit that ED nurses can be pretty jaded and cynical (I was an ED nurse, so I can say that) and there's no reason for them to be rude or condescending or dismissive to EMS folks. But again, they have a different perspective and a different set of priorities, so it shouldn't surprise anyone that communication isn't alway smooth.

    Basically, what seems important to a care provider in one setting isn't necessarily important to a care provider in another setting. Everything is relative.
     
    Last edited: Feb 8, 2018
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  18. Peak

    Peak ED/Prehospital Registered Nurse

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    I agree that there needs to be standardization in reports, but it's not as easy as just saying we want to do it.

    When I was at my prior regional pediatric trauma center I attempted to implement MIST reports for all of our incoming traumas where the EMT/Medic would then stay next to the primary RN and was available to answer further questions; we went out and attempted to implement this with multiple fire and EMS agencies, long story short no EMS agency wanted to buy in including our own flight program. The general consensus was that everyone wanted to give their full spiel and thought that they had it right. The trauma team then ignored EMS after about 30 seconds missing valuable information while simultaneously offending the EMS providers.

    Education and experience plays a huge piece. When I'm in the field my report isn't going to be the same as our Medics, and not even remotely close to the report that would be given by someone outside of our team who doesn't have extensive peds heme/onc experience. The same holds true for most calls, a trauma report from a Medic who has taken PHTLS and ATLS isn't going to be the same as someone who barely keeps up the minimum certs. A stroke call will have a different report from someone who is NIHSS certified compared to one who isn't. The challenge is that which provider a patient gets is largely luck of the draw.

    In an effort to improve EMS relationships my current system believes that we should give EMS one minute of silence before asking questions starting interventions. Not only is this not very practical EMS now feels like we are placating them rather than actually caring about their report. At times it feels like we can't win.

    What has actually built our relationship with EMS? Going into the lounge or the bay and inviting in crews to look at imaging and labs, and then discussing the case with them like professionals. Apologizing for a quip that escaped my mouth and acknowledging that it wasn't appropriate. Genuinely seeking out their opinion on how we can improve our care for the patient. Real mutual respect, not faking it and spouting out some canned phrases.
     
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  19. EMTlash

    EMTlash Forum Probie

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    I always give as through of an report as I can and there has been times where my partners tell me that they dont need all that info or that they already got a report. But you know what I love to do through assessments so I do check lung sounds and Pupils therefore I include everything in my hands off report and it really comes down to how much you care or how much info you really have. There are times that all you know is that pt was found unconscious/unresponsive and you have been bagging him ever since you found him. Even then I try to gather as much info as possible because in EMS any info could be helpful, whether it is to find out the candy box that the pt took candy from and is "feeling weak now" or the fact that he was involved in a TC and is having chest pain now.
     
  20. Bullets

    Bullets Forum Knucklehead

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    In a SNF, yes. The staff is difficult, absent, ill informed, and otherwise not a great group of people to work with.

    At the ER, no. We have a great relationship with the staff there.
     

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