Handover Improvement within the Emergency Care Setting ...
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Aus dem Universitäts-Notfallzentrum des Universitätsklinikums Freiburg im Breisgau Handover Improvement within the Emergency Care Setting: Implementation and Training of New Mnemonics in a German Emergency Department INAUGURAL-DISSERTATION zur Erlangung des Medizinischen Doktorgrades der Medizinischen Fakultät der Albert-Ludwigs-Universität Freiburg im Breisgau Vorgelegt 2018 von Nora Vanessa Lennartz geboren in Stuttgart
Transcript of Handover Improvement within the Emergency Care Setting ...
Aus dem Universitäts-Notfallzentrum
des Universitätsklinikums
Freiburg im Breisgau
Handover Improvement within the Emergency Care
Setting: Implementation and Training of New
Mnemonics in a German Emergency Department
INAUGURAL-DISSERTATION
zur
Erlangung des Medizinischen Doktorgrades
der Medizinischen Fakultät
der Albert-Ludwigs-Universität
Freiburg im Breisgau
Vorgelegt 2018
von Nora Vanessa Lennartz
geboren in Stuttgart
Dekan: Prof. Dr. Norbert Südkamp
1. Gutachter: Prof. Dr. med. Hans-Jörg Busch
2. Gutachter: PD Dr. Dirk Maier
Jahr der Promotion: 2020
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Table of Contents
I. List of abbreviations ....................................................................................................... II
II. List of tables ...................................................................................................................III
III. List of figures ................................................................................................................. IV
IV. Abstract .......................................................................................................................... V
V. Deutsche Zusammenfassung ........................................................................................ VI
1. Introduction and Background .......................................................................................... 1
1.1. Standardized handovers ......................................................................................... 3
1.1.1. Literature review ............................................................................................... 3
1.1.2. Advantages and disadvantages of handover .................................................... 4
1.2. Importance of standardisation in the emergency department .................................. 5
1.2.1. Relevant interfaces, mnemonics and communication training .......................... 7
1.2.2. Stressed personnel and patient satisfaction ....................................................11
1.2.3. Patient safety ..................................................................................................13
2. Study design and methods ............................................................................................14
2.1. Study design ..........................................................................................................14
2.2. Methods .................................................................................................................15
2.2.1. Mnemonics: ID-PHONE and ID-S2A2MPLE .....................................................15
2.2.2. Survey Questionnaires ....................................................................................18
2.2.3. Questionnaires for emergency medical services .............................................19
2.2.4. Questionnaires for patients ..............................................................................22
2.2.5. Questionnaires for ED staff .............................................................................23
2.3. Training and implementation of the new protocols ..................................................24
3. Results ..........................................................................................................................26
3.1. Emergency medical service ....................................................................................26
3.2. Patient and ED-staff ...............................................................................................32
3.3. Stress coping and communication mechanisms .....................................................41
4. Discussion .....................................................................................................................44
4.1. New Mnemonics for different operators: ID-S2A2MPLE...........................................44
4.2. Training and new handover: ID-PHONE .................................................................46
4.3. Downfalls and recommendations for further research .............................................48
5. Conclusion ....................................................................................................................51
VI. Publication bibliography .................................................................................................53
VII. Appendix .......................................................................................................................59
VIII. Conflict of interest ..........................................................................................................70
IX. Acknowledgements .......................................................................................................71
II
I. List of abbreviations
ED Emergency Department
EMS Emergency Medical Service
UNZ Emergency Department of the University Hospital of Freiburg
WHO World Health Organization
NTS Non-technical skills
III
II. List of tables
Table 1: Handoff Mnemonics common in emergency care……………………………….10
Table 2: ID-PHONE Protocol for medical rounds during handover…………………….. 17
Table 3: ID-S2A2MPLE mnemonic………………………………………………………… 18
Table 4: Number of Ambulance Operators, who filled out the questionnaire during both
survey periods. A disclosure was only given in half of the questionnaires….. 32
Table 5: Importance ratings, comparing ED staff and patients, pre- and post-
intervention…………………………………………………………………………. 36
Table 6: Perception and use of stress management and communication techniques by
ED-staff……………………………………………………………………………... 42
Table 7: English translation of the ED-staff questionnaire concerning stress
management techniques and patient
treatment………………………………………………........................................ 64
IV
III. List of figures
Figure 1: Workflow from preclinical assessment of the patient to his or her discharge from
the emergency department of the University Hospital of Freiburg…………… 20
Figure 2: Mean importance rated by Paramedics from the Ambulance Services, pre-and
post-intervention…………………………………………………………………… 29
Figure 3: Mean satisfaction rated by Paramedics from the Ambulance Services, pre-and
post-intervention, corrected for importance…………………………………….. 30
Figure 4: Importance and satisfaction ratings of handover from EMS to ED, rated by ED-
staff …………………………………………………………………………………..31
Figure 5: Mean importance rated by patients and emergency department staff pre-and
post-intervention…………………………………………………………………… 34
Figure 6: Comparison of satisfaction ratings of the three most important items rated by
patients……………………………………………………………………………… 35
Figure 7: Comparison of satisfaction ratings of the three items rated by patients as most
unsatisfying………………………………………………………………………… 37
Figure 8: Mean satisfaction rated by patients and emergency department staff pre-and
post-intervention…………………………………………………………………… 40
Figure 9: Ambulance service questionnaire……………………………………………….. 59
Figure 10: Patient questionnaire……………………………………………………………… 61
Figure 11: German version of the ED-staff questionnaire concerning stress management
techniques and patient treatment………………………………………………... 63
Figure 12: Questionnaire for ED-team concerning handover from emergency medical
service to ED……………………………………………………………………….. 66
Figure 13: Freiburger ID-S2A2MPLE scheme………………………………………………. 67
Figure 14: Freiburger ID-PHONE scheme…………………………………………………... 68
Figure 15: Freiburger ID-PHONE-handover scheme, with the specific tasks each position
needs to fulfill………………………………………………………………………. 69
V
IV. Abstract
BACKGROUND: Handing over information of a patient is a very critical part of the medical
treatment, since most information is lost at these intersections. This can easily lead to adverse
events and influence the safety of the patient. This is true especially in the stressful and often
unstructured settings of emergency medicine, where time pressure is leading, and many
different people are involved in the treatment of the patient. Mnemonics are a useful way of
structuring the information transfer and lowering stress levels.
OBJECTIVES AND METHODS: This study aims to evaluate the influence of newly designed
and implemented mnemonics, on the satisfaction of staff and patients with the treatment and
transfer of information at the emergency department of the University hospital of Freiburg,
Germany. Two new mnemonics were implemented: the ID-S₂A₂MPLE for handover between
the emergency medical service (EMS) and the emergency department (ED), and the ID-
PHONE for handover at ward rounds in the ED. A training on communication and stress-
management was conducted for ED-staff. The survey contained different questionnaires,
enquiring the satisfaction and importance ratings with different aspects of the patient treatment
and communication within the ED. These questionnaires were filled out by patients, ED- and
EMS-staff, before and after the implementation of the newly designed mnemonics and
accompanying staff training.
RESULTS: The findings show that patients overall were very satisfied with their stay in the ED.
They were most satisfied with the the personal attentiveness and professional competence of
the doctor in charge. Patients were least satisfied with the items concerning information
transfer (e.g. information about the next steps, explanations about medication, etc.). In nearly
all items, the ED-staff was significantly less satisfied with their work than their patients
(p<0.05). After the implementation of new mnemonics though, 14% more of the staff personnel
thought that ward rounds were better structured. Also, more staff recognized the importance
of understandable explanations. The EMS staff did not show any significant change in
satisfaction with the handover, though using a standardized protocol became significantly more
important after the implementation of the new standardized protocol (p<0.05).
CONCLUSION: The data shows that ED staff’s perceived lack of patient satisfaction often
results in a lack of staff contentment. Furthermore, it indicates the importance of clear
communication and continuous information transfer on patient’s self-reported satisfaction. ED
staff training on non-technical skills and the implementation of standardized protocols for
patient communication is strongly advised. This accounts for both triage and ward rounds.
Further investigations must show whether these tools also lead to an increase in patient safety
and staff satisfaction on the long run.
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V. Deutsche Zusammenfassung
HINTERGRUND: Die Übergabe von Patienteninformationen, ist ein kritischer Teil der
medizinischen Behandlung, da die meisten Informationen an diesen Schnittstellen verloren
gehen. Dies kann leicht zu unerwünschten Ereignissen führen und die Sicherheit der Patienten
beeinträchtigen. Dies gilt besonders in den stressigen und oft unstrukturierten Verhältnissen
der Notfallmedizin, in denen Zeitdruck herrscht und viele verschiedene Menschen an der
Behandlung eines Patienten beteiligt sind. Strukturierte Übergabeprotokolle sind ein nützliches
Mittel, um die Informationsweitergabe zu strukturieren und Stress abzubauen. ZIELE UND
METHODEN: Ziel dieser Studie ist es, den Einfluss neu konzipierter und implementierter
Übergabeprotokolle auf die Zufriedenheit von Personal und Patienten mit der Behandlung und
dem Informationstransfer in der Notaufnahme des Universitätsklinikums Freiburg zu
untersuchen. Zwei neue Protokolle wurden implementiert: das ID-S₂A₂MPLE für die Übergabe
zwischen dem Rettungsdienst (RD) und der zentralen Notaufnahme (ZNA) und das ID-PHONE
für die Übergabe bei Visiten in der ZNA. Für die ZNA-Mitarbeiter wurde ein Training zum
Thema Kommunikation und Stressmanagement durchgeführt. Verschiedene Fragebögen,
welche die Zufriedenheit mit und Wichtigkeit von verschiedenen Aspekten der Behandlung und
Kommunikation innerhalb der ZNA abfragten, wurden verteilt. Diese Fragebögen wurden von
Patienten, ZNA- und RD-Mitarbeitern vor und nach der Implementierung der neu konzipierten
Protokolle ausgefüllt. ERGEBNISSE: Die Ergebnisse zeigen, dass die Patienten insgesamt
sehr zufrieden waren mit ihrem Aufenthalt in der ZNA. Besonders positiv bewertet wurden
sowohl die persönliche Aufmerksamkeit als auch die Fachkompetenz des behandelnden
Arztes. Am wenigsten zufrieden waren die Patienten mit der Informationsvermittlung (z.B.
Informationen über die nächsten Schritte, Erläuterungen zur Medikation, etc.). In fast allen
Fällen waren die ZNA-Mitarbeiter mit ihrer Arbeit deutlich weniger zufrieden als ihre Patienten
(p<0,05). Nach der Einführung der neuen Protokolle waren jedoch mehr Mitarbeiter der
Meinung, dass die Visite besser strukturiert sei. Auch erkannten mehr Befragte die Bedeutung
verständlicher Erklärungen an. Die RD-Mitarbeiter zeigten keine signifikante Veränderung in
der Zufriedenheit mit der Übergabe, obwohl die Verwendung eines standardisierten Protokolls
deutlich an Bedeutung gewann (p<0,05). FAZIT: Die Daten zeigen, dass die wahrgenommene
mangelnde Patientenzufriedenheit des ZNA-Personals oft zu einer mangelnden Zufriedenheit
des Personals führt. Darüber hinaus zeigt es die Wichtigkeit einer klaren Kommunikation und
eines kontinuierlichen Informationstransfers für die Zufriedenheit der Patienten. Es wird
dringend empfohlen, das ZNA-Personal über nicht-technische Fertigkeiten und die
Implementierung von standardisierten Protokollen für die Patientenkommunikation zu schulen.
Untersucht werden muss weiterhin, ob diese Instrumente auch langfristig zu einer Erhöhung
der Patientensicherheit und Mitarbeiterzufriedenheit führen.
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1. Introduction and Background
In 2007, the World Health Organization (WHO) published a report on how to elevate patient
safety in the clinical setting (WHO 2007b). One of the main aspects was improving the
handover process of patients. In the past few years, the need for enhancing handovers has
become ever so more prominent. Patient handover is essential to hospital care. It is a transfer
of knowledge, responsibility and accountability for the care and treatment of a patient or a
group of patients (Sujan et al. 2014, p. 7). It may occur between staff of the same profession
(e.g. between members of the nursing staff) or different professions (e.g. ambulance staff to
medical doctor). It is a crucial part of hospital staff routine, which can contribute to a hospitals
resilience or be a source of errors and adverse events. This is why standardization of
handovers has been establishing itself in the medical landscape.
The goal of this study was to implement new patient handover systems in an emergency ward
and determine, whether this has an influence on the satisfaction of staff and patients in this
ward. Furthermore, a training of communication skills and structuring handovers for the staff
of this emergency ward was done. Two intersections, where handover is an institutional part
of the workflow, were altered. The handover mnemonics themselves were newly created
specifically for each setting. The first, was the intersection where the first responders/
ambulance staff hand over the patient they collected and treated, to the emergency ward staff.
Here the Handover Mnemonic “ID-S₂A₂MPLE” was implemented. The second, concerns the
handover between the shifts in the emergency ward itself. Here the “ID-PHONE” was to be
used as a mnemonic for handing over the patient information. These were mnemonics newly
created specifically for each setting. Satisfaction and importance ratings were surveyed before
and after the implementation of the new handover schemes and accompanying communication
training. The details of the new mnemonics, as well as the design of the conducted study, will
be illustrated further on in this paper. This following section will focus on the literature of patient
handover and the reason for its importance. It will discuss different mnemonics, their meaning
and field of operation. In the end, the benefit of implementing a structured handover process
will be critically discussed.
“Handovers can contribute to an organization’s resilience because they provide clinicians with
an opportunity to capture any errors or threats to patient safety” (Raduma-Tomàs et al. 2011).
If not done thoroughly, information loss during handover can easily lead to adverse events and
consequently risk patient safety (Knutsen and Fredriksen 2013; Manser and Foster 2011;
Manser et al. 2010; Gordon and Findley 2011; Vries et al. 2008, 2008). In addition, handover
can enhance teamwork and group cohesion as well as serve aspects of training and
socialization (Horwitz et al. 2009). In highly organized and structured sectors, like ambulance
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care, the flight sector and many more, standardized handovers are already an established
state–of–the–art (Cheung et al. 2010). In emergency care however, this is not easily done.
Department-crowding, event-driven shift work at high paces, time pressure as well as inter-
professional communication and concurrent distractions, while the patient is in an ‘at risk’ state,
lead to handover settings, prone for errors and misunderstandings (Kulla et al. 2014; Manser
et al. 2010; Talbot and Bleetman 2007). To encounter this risk, especially in the field of
emergency medicine, standardizations can help avoid high numbers of adverse events
(Manser et al. 2010; Kreimeier and Sefrin 2012, p. 287; Keebler et al. 2016; Starmer et al.
2014b). In anglophone countries this has already been in progress for several years and many
studies, accompanying the implementation of new standards, have been published (Raduma-
Tomàs et al. 2011; Keebler et al. 2016; Flynn et al. 2017; Wood et al. 2014). However, little
scientific documentation has been collected in German EDs about the effects of standardized
protocols on patient care and security (Waßmer et al. 2011; Kreimeier and Sefrin 2012; Gordon
et al. 2012).
Hospital Departments for emergency care are common in English speaking countries. In
Germany´s medical landscape EDs have only arisen in the last decade and are constantly
spreading and growing throughout the country (Kirsch et al. 2014; Kumle et al. 2014) . At
present time, there is no board certification or standard training for ED-staff in Germany
(Putensen 2012). Since 2003 a major effort has been put into the restructuring process of
emergency medical care (Gries et al. 2017). In 2013 leading emergency physicians published
a report, in which they positioned themselves for enhancing the Development of Emergency
Departments in Germany, including an educational focus on emergency care within the
medical education, and called for more evidence-based research in emergency care (Reimer
Riessen). In 2016, they specified this by calling for an increase in quality management and
standard documentation, as well as standard operating procedures (Kulla et al. 2014; Kulla et
al. 2016). However, the board certification for emergency physicians has yet to be established,
as well as a standard in documentation and standard education (Kulla M., Brammen D.,
Greiner F. et al. 2016; Quintel and Kumle 2011; Gries et al. 2017). The standard in education
is now in the process of being implemented. An 80-hour course, developed by the German
society for interdisciplinary emergency- and acute medicine (DGINA), is in offering, since the
beginning of 2018. To enable a quality assessment, all of the above has to be developed for
emergency care departments (Kulla M., Brammen D., Greiner F. et al. 2016; Gries et al. 2017).
In the following sections I will go more into depth on the theory and usage of handovers, the
importance of medical education sessions, especially concerning stress factors of medical
staff, and eventually discuss the influence of these topics on patient safety.
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1.1. Standardized handovers
This paper analyzes the implementation of new standardized protocols for handovers in an
emergency department. Here, there are several questions to consider: Where do handovers
take place? What information should be included? And could standardization improve to the
handover process? In the following section, the literature on this topic will be reviewed and the
benefits and pitfalls of handovers discussed. Thereafter, the importance of handovers in an
emergency department will be illustrated. Furthermore it will be explained which interfaces are
of relevance in the standardization process and some examples of already existing handover
protocols given.
1.1.1. Literature review
Literature on handover protocols in emergency departments has been emerging in the last
decades. Often, a parallel is drawn to flight crews, who have been using structured protocols
and cross-checking techniques for many years (Cheung et al. 2010; Gerstle 2018; Powell-
Dunford et al. 2017; Lark et al. 2018). They are highly effective in their work and the number
of adverse events is kept a very low level. This is also what the medical care sector seeks to
achieve. In anesthesia, surgery, pre-clinical emergency care and intensive care, this has
already been established. In the emergency sector, however, in-hospital handover has
remained quite inconsistent. The literature reveals a major lack in structured handovers
(Cheung et al. 2010, p. 177; Manser et al. 2010; WHO 2007b; Meisel et al. 2015; Dawson et
al. 2013; Owen et al. 2009, p. 105; Wood et al. 2014, p. 2). In the U.S., a study revealed that
in a number of internal residency programs, written or oral key clinical information was
available only two thirds of the time (Raduma-Tomàs et al. 2011). “Such findings have led to
calls for a more structured approach to doctors' shift handovers” (Raduma-Tomàs et al. 2011).
Standardisations are seen as a major contributor to a shared understanding of a situation, a
shared language (Manser et al. 2010; WHO 2007b; Owen et al. 2009, p. 104; Lark et al. 2018).
Poor handover practices result in information loss, dissatisfaction of staff as well as patients,
and confusion (Marmor and Li 2017, p. 297). In the UK, a special effort was made for improving
ambulance handovers. In 2013, the Clinical Commission Group (CCG) took up responsibility
for this task and made it a top priority in clinical restructuring processes (Wood et al. 2014). In
fact, a major part of the literature on emergency handover is found in the Anglophone sector
(Gordon and Findley 2011; Gordon et al. 2012).
However, most studies analysing the effect of structured handover protocols implementation
on clinical outcomes and patient security lack a convincing study design. The analyses often
concentrate on information loss, time loss and communication downfalls, while actual outcome
of a patient or the number of adverse events are not part of the studies (Manser and Foster
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2011, p. 185; Manias et al. 2016; Dawson et al. 2013; WHO 2007b; Manser et al. 2010).
Furthermore, the studies are mostly conducted with small case numbers. This leads to a
questioning of the significance and need for further research. However, big case studies, where
the outcome of the patient is registered and the reasons for adverse events analysed, require
a great amount of resources. Therefore, the strategy of conducting several smaller case
studies and comparing these in the aftermath, is the second-best option to follow.
Nevertheless, the literature available has revealed some interesting information on this topic.
1.1.2. Advantages and disadvantages of handover
In general, the analyzed literature favored standardized handover protocols for each medical
specialty. The remaining question here is, do standardizations actually provide benefits? What
are the theories behind the arguments? And is there empirical evidence for this?
In 2004, WHO created a committee on patient security. The task of this committee was to
identify factors influencing patient security and formulating best practices to prevent avoidable
risks of patients’ lives (WHO 2007b). These are risks, relating to e.g. communication,
documentation or institutional omissions, but not to unavoidable complications in the clinical
status of a patient. It was meant to give advice as to how an institution can raise its resilience
to avoidable adverse events. They published a report and guideline in 2007, in which one of
the most important aspects was “communication during patient-handovers” and assuring
“medication accuracy at transition of care” (WHO 2007b). They pledge for a standardized
protocol as an accurate tool to optimize this.
Standardization establishes a basis for a shared mental model, seeks to minimize
communication misunderstandings and reduce the time needed to transfer all relevant
information (Raduma-Tomàs et al. 2011; Manser et al. 2010; Rüdiger-Stürchler et al. 2010).
By having set the relevant information for a good patient care, a great chance is given to detect
errors and overseen important medical parameters by the medical staff involved in the
handover (Raduma-Tomàs et al. 2011; Marmor and Li 2017; Keebler et al. 2016). Starmer et
al. (2014) reported that all medical errors were reduced by 23% and preventable adverse
events by 30% through the implementation of the I-PASS Mnemonic in nine hospitals in the
USA (Starmer et al. 2014b, p. 1808). The I-PASS scheme contains the items illness severity,
patient summary, action list, situation awareness and contingency plans, as well as synthesis
by receiver. The flow of information handed over runs along those items (Starmer et al. 2014b,
p. 1804), (Heilman et al. 2016). Standardized handovers are not only an aid against medication
and information error, they streamline the patient care process. Physicians have a clear
guideline that accounts for all relevant information, and a functional running order by which to
question and examine a patient and present their findings. Furthermore the risk of “anchoring”
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is reduced (Cheung et al. 2010). ‘Anchoring’ describes the bias, which is caused, when a
person has a made-up opinion and presents information from that particular point of view.
Through this, the receiving person can easily be misled by the bias of rapport. Going back to
the example of flight crews, ”Highly effective flight crews use one third of their communication
time to discuss threats and errors in their environment, regardless of workload, whereas poor-
performing flight teams spend about 5% of their time on those issues” (Cheung et al. 2010,
p. 172).
As shown, there is an abundance of arguments in favour of a standardization during handover.
But studies, which statistically prove the benefit are rare. Therefore, one must not ignore the
downfalls this could have on the work. In the literature, a major argument for a standardized
protocol, is the handover time reduction. But this is also discussed controversially. Keebler et
al. (2016) argues that more time is actually needed for the information transfer, as some
information can be missed due to omission from the protocol (Keebler et al. 2016). Also, young
doctors do not receive a sufficient training in structuring handovers. Solely implementing
protocols without the necessary training has shown to bring little benefit (Gordon and Findley
2011; Lark et al. 2018). In fact, very little research on this topic has shown an actual benefit of
structured protocols (Talbot and Bleetman 2007; Wood et al. 2014; Manser et al. 2010; Manser
and Foster 2011). This probably is mostly due to the research quality and study designs but
weakens the strong call for standardization.
In general, handovers are said to bring about improvements in quality and time, as well as
shared understanding. They are used in flight crews on a regular basis and bring a substantial
benefit in that field. In the emergency medicine landscape, they are beginning to be
implemented following recommendations of the WHO (WHO 2007b; Cheung et al. 2010). But
more studies proving the benefit are needed, because as for now, no strong empirical evidence
has been proven (Manser and Foster 2011; Riesenberg et al. 2009).
1.2. Importance of standardisation in the emergency department
In the emergency settings, several factors can easily lead to adverse events and errors. It is a
stressful setting, in which time is a crucial factor for the outcome of the patient and many
different persons are involved in the care and treatment of the patient. There are many
checkpoints in which information can be lost, due to the unstructured situation that exists
because of the nature of emergencies. During handovers from ambulance staff to ED, but also
within the emergency ward itself, information is easily lost or forgotten. “ED transition is
especially vulnerable because transitions of care take place in an environment that is event-
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driven, time-pressured and prone to concurrent distractions while the patient is in an ‘at risk’
state” (Manser and Foster 2011).
Handover from EMS (emergency medical service) to ED ward is a very unique situation, since
the teams do not share the same workplace and same communication basis (Meisel et al.
2015). They come from a different standpoint and background. Information-loss can easily and
quickly lead to adverse outcomes (Vries et al. 2008). Especially in the emergency setting,
handovers are crucial for the success of the treatment of the patient. Here, standardizations
are a logical conclusion. Among all specialties, emergency medicine is probably one of the
most stressful ones. Physician burnout lies at over 60% (Goldberg et al. 1996). Distraction,
time pressure, unexpected events as well as interruptions all lead to stress, which can lead to
a decrease in the ability of logical thinking. This means that in a stressful situation it is very
important to have a procedure to follow and not having to constantly question whether the
handover included all relevant information. Protocols may serve as visual aids or prompts as
to what information needs to be passed between providers. These aids supplement healthcare
providers, so they do not rely solely on their memory for the information that needs to be
passed on (Keebler et al. 2016; Powell-Dunford et al. 2017; Gerstle 2018). The same can be
said for handovers during ward rounds. Here the patients are often still in an at-risk state, while
time-pressure forces for quick diagnostics and treatment. Again, a given structure should lead
to a more focused and effective handover. A substantial amount of information is collected, but
it is important to filter the relevant information out (Lendemans 2012). Several studies have
shown that there is a substantial degree of information loss in emergency settings sometimes
resulting in less than half of the information being transferred to the attending doctor’s
admission note (Knutsen and Fredriksen 2013; Gordon and Findley 2011; Manser et al. 2010).
In the end, this could lead to a discontinuity in care of the emergency patient. Because of the
setting and surroundings in emergency care, complete attentiveness during handover is often
not given (Talbot and Bleetman 2007). In a video analysis of 96 trauma handovers in the USA,
Wood, et al. found that only 72.9% of the key pre-hospital data points transmitted by
ambulance staff were documented by the receiving hospital staff (Wood et al. 2014, p. 2). In
Australia a similar analysis showed that only 67% of information given by paramedics to the
in-hospital team was documented (Wood et al. 2014, p. 2).
Nevertheless, Owen et al. contested in their study that “despite an awareness by receiving
staff that they often did not listen attentively during handover, there was agreement that
handover formed an important part of the overall decision-making process” (Owen et al. 2009,
p. 104). At handovers, a fresh and new look onto the information of the patient is given. This
can also bring upon new chances and ideas for the further treatment. Handovers pose an
opportunity for exchange of knowledge and opinions, cross-checking and error-detection
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(Manser et al. 2010). A study, conducted on patients with sepsis, found that in most cases,
communication problems were the leading reason for adverse events (Matthaeus-Kraemer et
al. 2016). Again, the importance of prompts or aids for the communication process in the
stressful setting of emergency patients is underlined.
1.2.1. Relevant interfaces, mnemonics and communication training
In an emergency ward everyone must constantly be ready to help out and take up work of
others, in order to treat the patient at risk adequately. Here information is collected and
constantly transferred between staff. Often enough, this information does not reach the person
in charge of the patient. This is a situation which is given due to the nature of emergencies.
Some of this information loss is unavoidable, but other can be reduced. The feasible
interventions are located at pre-assigned checkpoints and at a handover of responsibility.
These are points in time, when information is transferred in a pre-defined setting, and
information-loss can easily be tackled through structuring this process. In emergency wards a
handover of responsibilities is given during: 1. Handover from EMS (emergency medical
service) to ED staff, 2. Handover within the ED ward between ED staff and 3. Inner-clinical
handover from ED ward to another receiving ward. Pre-assigned checkpoints can differ and
are set by each clinic. In this study the University Hospital of Freiburg set the morning rounds
with the managing senior physician, as predefined checkpoints. Here a handover between the
attending physicians has already taken place and the rounds are used to discuss the further
proceedings, as well as attend to and inform the patient. In these certain points in time,
information transfer can most easily be optimized. As discussed above, protocols using
mnemonics and communication training are an effective tool for this.
The WHO Collaboration Centre for Patient Safety Solutions recommends the use of
mnemonics and training in communication as an effective tool against information loss (WHO
2007a). They recommend the use of the SBAR concept (Situation, Background, Assessment
and Recommendation) (WHO 2007b). They also stress the importance of allocating sufficient
time, without interruptions for communication and responding to questions. Furthermore, the
exchange of information should be limited to that which is necessary for providing safe care of
the patient. Alongside advancing communication between different providers, a training for
communication within the organization is also required. Providers are summoned to
“incorporate training on effective hand-over communication into the educational curricula and
continuing professional development for health-care professionals” (WHO 2007b). These
recommendations were developed through research results on patient safety. A review on
patient safety and handover showed that in the USA and in the UK, handovers were found to
be one of the greatest causes of errors in the treatment of patients (Gordon and Findley 2011,
p. 1082). This review also found a general paucity of training of junior doctors in structuring
8
communication and handover, while other reviews underline how dependent handover quality
is, on the training young doctors receive (Raduma-Tomàs et al. 2011; Gordon and Findley
2011). “Incomplete information transfer and consequently assessments, repetition, delayed
treatment, medication errors, avoidable readmissions, increased patient morbidity and
mortality” (Marmor and Li 2017, p. 297) are all factors which can be avoided by training and
knowledge of handover processes. There is a substantial number of mnemonics, which
already exist for handovers. In Germany further mnemonics are the following: I-PASS, SBAR,
SOAP, DeMIST, SAMPLE(R) and the classical ABCDE scheme for pre-clinical assessment.
The information, which should be transferred in these mnemonics naturally depends on the
setting in which it is used (Talbot and Bleetman 2007; Dossow and Zwissler 2016; van der
Wulp et al. 2017; Heilman et al. 2016; Starmer et al. 2014b, p. 1804, 2014b; Starmer et al.
2014a; Ilan et al. 2012). In this study, we implemented the ID-S₂A₂MPLE for handovers
between ambulance and emergency ward and the ID-PHONE for handovers between shifts1.
Both handover schemes took up elements of already existing schemes and adjusted them for
the specific setting they were meant to be used in.
Pre-clinical handovers must be kept brief and contain the crucial` information for keeping a
patient alive. Once this patient is put in the clinical setting, the detailed treatment begins and
therefore a more detailed handover is necessary. The ABCDE (Airway, Breathing, Circulation,
Disability and Environment/Exposure) scheme has established itself as the best mnemonic to
work with pre-clinically. It is widely spread in all kinds of advanced life support algorithms. Pre-
clinical care has been one of the first medical sectors, recognizing the importance of
mnemonics and implementing these nationwide. It is already taught for undergraduate
students and is essential in an emergency setting. Paramedics often use this scheme to
handover a patient to the admitting hospital. This is logical to a certain extent, since much
information has probably been collected by the ambulance crew and it provides a scaffold for
important details about interventions and treatment to be transferred.
In the clinical setting, there are certain features every mnemonic contains. These are also the
features every handover should contain. First and foremost, they all contain the assessment
of the current situation, symptoms and chief complaint of the patient. Then, a brief summary
of medications, allergies and other important prior medical interventions must be included into
the mnemonic. Objective parameters like examined physical status, as well as laboratory or
imaging results, should also be communicated. Already known information about the patient,
as well as already conducted treatment and the consequences this had, is an additional part
of every mnemonic. In the end, a plan or recommendation for further treatment is given.
1 These two handover schemes will be discussed in detail further on, in the section on the Study design and methods
9
The biggest difference of these mnemonics is their broadness. SOAP (an acronym for
Subjective, Objective, Assessment, and Plan) for example, is held quite general, in order to
adjust and specify the content according to its field of use (Talbot and Bleetman 2007; Ilan et
al. 2012). It is similar to SBAR (accounting for Situation, Background, Assessment and
Recommendation), which has been established in all kinds of medical fields and used by
nursing a well as doctoral staff (Achrekar et al. 2016; Ting et al. 2017). A recent study on this
mnemonic even found that “[…] teamwork climate, safety climate, job satisfaction, and working
conditions, significantly improved […]” through its implementation (Ting et al. 2017). It is also
frequently used for patient handovers in high-risk fields, like emergency medicine (Dossow and
Zwissler 2016, p. 149; van der Wulp et al. 2017; Velji et al. 2008). SAMPLER is a more detailed
mnemonic, generally used in emergency settings and can be of special meaning for
emergency anaesthesia (Lars Schmitz-Eggen 2018). It stands for Symptoms, Allergies,
Medication, Past Medical History, Last Meal, Events prior to incident and Risk Factors (Lars
Schmitz-Eggen 2018). Again, this mnemonic is meant to cover the most important information
of a patient in the shortest time period possible. I-PASS (Illness severity, Patient summary,
Action list, Situation awareness and contingency plans, and Synthesis by receiver) has been
developed a few years ago and tested in a major study in the paediatric settings, revealing
how important handover structure is for patient security (Starmer et al. 2014a; Starmer et al.
2014b). It can be used in several different clinical settings and does not have a specific focus.
A very recent study found it to be compatible for an ED-setting, if it is modified for context,
brevity, and clarity (Heilman et al. 2016). DeMIST (Patient Demographics, Mechanism of
injury/illness, Injuries (sustained or suspected), Signs and Symptoms, including observations
and monitoring, Treatment given) is mainly used for emergency ward settings and at
handovers from pre-clinical to clinical settings (Riesenberg et al. 2009; Talbot and Bleetman
2007). It is best located in the Trauma section, since it focuses on injuries and its mechanisms.
In our study we have taken the basic essentials of these handover mnemonics and specified
them for their particular use. In the end we worked out detailed handovers, adapted for the
demands of the respective situation.
10
Table 1: Handoff Mnemonics common in emergency care, Source: (42)
MNEMONIC FIELD OF USAGE DESCRIPTION
ABCDE Pre-clinical advanced life support
emergency assessment
Airway,
Breathing
Circulation
Disability
Environment/Exposure
SBAR All kinds of medical fields, adapted
accordingly
Situation
Background
Assessment
Recommendation
I-PASS All medical fields, special meaning
for surgery and emergency care
Illness severity
Patient summary
Action list
Situation awareness and contingency plans
Synthesis by receiver
DeMIST Ambulance/emergency department
Patient Demographics
Mechanism of injury/illness
Injuries
Signs and Symptoms
Treatment
SAMPLE(R) Ambulance/emergency department
Symptoms
Allergies
Medication
Past Medical History
Last Meal
Events prior to incident
Risk Factors
SOAP All medical fields, special meaning
for surgery and emergency care
Subjective
Objective
Assessment
Plan
Training of these mnemonics is an essential part of a successful implementation and at the
same time also an essential contributor to improvements in communication. Formal training is
needed for effective handovers (Owen et al. 2009; Manias et al. 2016). In fact, studies have
revealed that if no training accompanies the implementation of a newly implemented handover,
no positive effect can be observed (Sujan et al. 2014, p. 10; Raduma-Tomàs et al. 2011). This
11
fact was also respected by our study, integrating a formal training, in which the handover itself
was thematised, as well as non-technical communication skills (NTS) and skills to reduce
stressors at handover. “NTS has been previously defined as the cognitive and interpersonal
skills that complement an individual’s professional and technical knowledge in the facilitation
of effective delivery of a safe service” (Gordon et al. 2017, p. 1). The training itself was a
theoretical assessment of these skills, without a practical or simulation training. This was
aligned by the fact that non-technical skills are becoming ever so more important and training
for these in the medical sector is increasing in numbers (Gordon et al. 2017; Matthaeus-
Kraemer et al. 2016; Owen et al. 2009; Sirgo Rodríguez et al. 2018). Apparently the medical
sector has been learning from other sectors, like e.g. the flight sector, where communication
and teamwork skills have been central to non-technical skills training (Gordon et al. 2017;
Knutsen and Fredriksen 2013; WHO 2007a). The idea behind these trainings is that the
workflow is optimized, adverse events reduced, and stress minimalized. Studies have shown
that adverse events can be reduced, but as mentioned above, results suggest that this does
not generally apply (Gordon et al. 2012; Gordon and Findley 2011; Marmor and Li 2017). In a
study conducted to identify barriers to the early detection and timely management of severe
sepsis, the major causes identified were all related to communication problems (Matthaeus-
Kraemer et al. 2016). Another study, collecting data from different intensive care units across
the United States found that 49% of adverse events were at least partly due to inadequate
training or education and 32% because of teamwork issues (Reimer Riessen 2006). Ever so
more supporting the argument that non-technical skills are an imminent component of best
patient care. Unfortunately, this has only become prominent in the last few years and education
of future medical personnel does not teach these factors sufficiently (Gordon and Findley 2011,
p. 1082; Owen et al. 2009, p. 106). This often leads to failures in communication and a lack of
stress management. More investigation is needed to prove whether stress can be reduced and
if handover communication can be optimized through training.
1.2.2. Stressed personnel and patient satisfaction
Stress for hospital personnel is another obstacle for best patient care. It is not only a hindrance
for optimal work in an ED, but also contributing to patient dissatisfaction. Studies revealed that
approximately one-third of the factors influencing patient satisfaction, is whether or not a
medical employee is stressed (Anagnostopoulos et al. 2012, p. 401). “Although most of the
variation in patients’ satisfaction occurs at the patient level, the fact that 34.4% of total variation
occurs at the physician level, after adjustment for patients’ characteristics, is a strong
endorsement for the use of physician-related factors in surveys of patients’ satisfaction”
(Anagnostopoulos et al. 2012, p. 408). Stress itself is the leading cause of burnout, which is
often used as a measurement tool for stress. Lu, et al. (2015) found that the quality of care
12
physicians provide to patients, is related to the level of burnout (Lu et al. 2015). This means
that burnout leads to inferior care of patients, therefore less patient satisfaction and one could
imagine patient security to be at stake too. In fact, it was found that high levels of burnout
significantly correlated with suboptimal patient care: patients were admitted or discharged
early, options were not discussed, questions not answered, too many tests were ordered, pain
not treated adequately, and plans were not discussed with the rest of the staff (Lu et al. 2015).
Additionally, important handoffs were not communicated correctly (Lu et al. 2015). Not only the
quality of the work is influenced negatively through burnout, longer periods of absenteeism,
more rotations, and attempts to leave the profession are another consequence (Ríos-Risquez
and García-Izquierdo 2016, p. 62). Emergency care, because of its high stress levels, varying
working hours, and unpredictability is especially vulnerable to this. “Among all specialties,
emergency medicine (EM) experiences the highest levels of physician burnout at over 60%”
(Goldberg et al. 1996). This probably is because of emergency medicine being challenging
both physically and emotionally (Lu et al. 2015). In order to counter this stress, structure and
stress training are essential tools.
With regards to patient satisfaction, it is important to acknowledge that it is multidimensional
and influenced by many other things than solemnly the stress level of the treating physician.
These cannot be accounted for completely, but important factors can be distinguished. Next
to the personality and proneness to dissatisfaction of the patient itself, emotional
accompaniment through the medical staff is a very important factor (Neumayr et al. 2011;
Grøndahl et al. 2013). Information transfer and understandable explanations, as well as
knowledge about the next steps are also important for higher satisfaction ratings (Neumayr et
al. 2011). In the emergency sector, it is especially important for patients to be present at a
face-to-face handover, therefore seeing the person taking over the responsibility of the
patient’s care and being part of the verbal information transfer (Neumayr et al. 2011). Of
course, factors like the quality of treatment, waiting times, and quality of care should not be
neglected in this line of thought. In general, patient satisfaction is important for the treating
personnel, as well as the hospital itself. It can be seen as an indirect measure, an indication of
the quality of treatment. This study accounts for this through the use of patient questionnaires,
which will be explained in detail further along in this paper.
In the end it is important to mention that patient satisfaction also influences the level of stress
of physicians. Doctors who perceived patient satisfaction be higher, scored lower on burnout
levels (Weng et al. 2011). Therefore, the perceived satisfaction level of patients is a very
important factor for stress levels of ED staff, and consequently, also for the quality of treatment.
In the already quite stressful emergency setting, it is especially important to tackle these
preventable sources (namely patient satisfaction) of stress. Again, we tried to account for this
13
through questionnaires about stress levels and perceived satisfaction rates of ED-staff, as well
as training of non-technical skills.
1.2.3. Patient safety
Handover failures are one of the main causes contributing to patient harm. “The defining
attributes of patient safety include prevention of medical errors and avoidable adverse events,
protection of patients from harm or injury and collaborative efforts by individual healthcare
providers and a strong, well-integrated healthcare system” (Kim et al. 2015). Patient safety is
a multi-faceted concept, influenced by several different factors in addition to the quality of
handover. Aurora et al. stated in 2009 that “handovers [are] jostling for top position as one of
the hottest topics in the global patient safety arena” (Johnson and Arora 2009). As mentioned
above, the WHO listed handover standardization as one of the 9 most important factors for
improving patient security (WHO 2007a)2. But also many national programs, especially in the
UK, Australia and USA have established special taskforces for improving patient handover
(Kohn et al. 2009, cop. 2000; Department of Health 2000; Gordon and Findley 2011, p. 1082).
“Australian research examining medical clinical handover in EDs and in general, has identified
that poor handover practices result in incomplete information transfer and consequently
assessments repetition delayed treatment, medication errors, avoidable readmissions,
increased patient morbidity and mortality” (Marmor and Li 2017, p. 297). Many studies
identified that, especially in emergency departments, much information is lost during handover
(Ye et al. 2007; Manser and Foster 2011, p. 184; Meisel et al. 2015; Yong et al. 2008; Blum
and Tremper 2009). This information loss is of crucial significance in an emergency
department, where patients are at high risk and often timely intervention is central to a patients’
successful treatment. On top of that, overcrowding, noisy surroundings, patient relocation and
unexpected events are common in emergency departments. This poses a further threat to
patient safety. If information is lost it can not only have direct effects on the treatment of the
patient but also on various other aspects: increased lengths of stay, treatment delays,
confusion regarding care, medication errors, avoidable readmission and increased costs
(Sujan et al. 2014). This shows, how important standardization of the handover process is for
patient safety.
Since little research has been published about this, concerning German emergency
departments, evidence-based best practices cannot be developed.
2 Following items were listed as the 9 intervention points for advancing patient safety, by the WHO: 1. Look-Alike,
Sound-Alike Medication Names, 2. Patient Identification, 3. Communication During Patient Hand-Overs, 4. Performance of Correct Procedure at Correct Body Site, 5. Control of Concentrated Electrolyte Solutions, 6. Assuring Medication Accuracy at Transitions in Care, 7. Avoiding Catheter and Tubing Mis-Connections, 8. Single Use of Injection Devices, 9. Improved Hand Hygiene to Prevent Health Care-Associated Infection WHO 2007a
14
2. Study design and methods
This study analyses whether the handover restructuring process and training thereof lead to
an increase in patient and staff satisfaction and a subjective stress reduction in the staff. The
following section contains additional details about the theory behind this intervention and the
hypothesis of the causal contiguities. Furthermore, a rough summary of the initial situation of
the University emergency department of Freiburg (UNZ) is presented. The section will end with
the description of the Methods used for the survey and the conducted interventions.
2.1. Study design
We performed a single centre survey in the ED of the University Medical Centre of Freiburg –
Germany, where approximately 50.000 patients are treated annually. The study was
conducted throughout the years of 2015 until 2017. The focus was set on emergency patients
of internal medicine. All doctors and nurses took part in the restructuring process and survey.
We set two focus points of intervention and questioning. The first was the transition from pre-
clinical to clinical treatment. In practice this means handover from EMS to ED ward. The
second was the handovers given to the responsible senior physician during morning rounds in
the ED ward. The study consisted out of two main strands: Intervention and observational
research. The intervention was an implementation of standard mnemonics and predefined
handover procedures. The goal was to smoothen the handover process, improve
communication, lower staff stress levels, improve patient and staff satisfaction and on the long
run, enhance patient security. Two different mnemonics were implemented: the ID-S₂A₂MPLE
for the interface of the emergency medical services to emergency department, and the ID-
PHONE for ward rounds and anamnesis of the patient. The observational research was meant
to assess whether these goals were accomplished. The patients were chosen by chance and
capability to take part in a questionnaire. The goal to reach all staff, present during the time
period of data collection was only partly successful, due to time pressure or unwillingness to
answer the questionnaire. Since there was only a limited amount of data which could be
collected, some of the parameters were not obtained: Improvements in communication skills
and patient security could not be analysed. In theory, an enhancement of the factors should
be observed, but since we could not obtain any data, this can only be presumed.
The main goal of this work was, to structure handover processes in the emergency department.
It was recognized, by leading personnel that there is room for improvement in this area and
that interventions were sensible. To evaluate whether the interventions also fulfilled their
intended purpose, they were accompanied by this study, to obtain the necessary data.
Questionnaire data was collected before and after the restructuring process, to compare pre-
15
and post-intervention ratings of the handover process. Ambulance, ED-staff and patients were
questioned with different questionnaires, and the collected data analysed. The need for training
and collectively deciding on the best structure of handover was recognized in this process. A
training for ED-staff was held for this purpose, before the implementation of new handover
mnemonics and structures. Here, the importance of non-technical skills was underlined, and
the results of the questionnaires discussed. In a joint effort, the ID-PHONE mnemonic was
specified and tasks for each person taking part in the handover process (attending resident,
nursing staff and chief resident) defined. This mnemonic, which is specified below in the
following section, was intended for handovers during ward rounds in which the respective chief
resident is informed about the patient by the attending resident and attending nursing staff.
Furthermore, it should be used as a guide for taking over patients from the emergency medical
service and noting important patient information. In this way, all relevant information is already
collected in a structured manner and can easily be passed on in this manner.
For the emergency medical services another mnemonic was designed. The ID-S₂A₂MPLE. It
was adapted from the already existing SAMPLER mnemonic and specified for this setting (Lars
Schmitz-Eggen 2018). There was no training conducted for this mnemonic, but information
sent out to all EMSs, attending to patients who are delivered to the University Hospital of
Freiburg. Here a pre- and post-intervention survey was also conducted, to see whether
satisfaction rating rose through standardization.
2.2. Methods
In the first part of this section, the two different mnemonics which were implemented are
presented, followed by the different questionnaires used to obtain our data. In the last part, the
conducted training will be briefly described.
2.2.1. Mnemonics: ID-PHONE and ID-S2A2MPLE
The protocol acronym represents the systematic approach to the patient´s history and the
handover to the following shift of physicians and nurses. Always beginning with the
identification of the patient (ID) the sequence of handover runs along the PHONE-path. The
acute complaint or problem is then stated (P) including the mode of entry into the hospital (e.g.
EMS, admission by general practitioner or self-admittances). Then the past medical history (H)
including allergies and medication is discussed before the objective (O) vital signs and
laboratory findings and examination results are presented. This is followed by the next steps
(N) to be taken, and the possible discharge or admission to another hospital ward (E, German:
“Entlassung”- discharge). This mnemonic was meant to be used during morning ward rounds
16
where the attending physician and attending nurse handed over information about the patient
to the senior physician on duty.
In addition to the mnemonics, a specific procedure for handover was also enacted. Here, each
position got their own tasks and information that they were to pass on and ask for. Additionally,
the roadmap for communicating this information in a structured and understandable manner
to the patient was established. The handover was to take place outside of the patient’s room
for a variety of reasons. The first intention was to keep a personal relationship to the patient
and concentrate fully on her or his needs, when being in contact. Secondly, the staff can
discuss the illness and situation of the patient more freely, using medical technical terms, with
the patient not being present. This enables the treating staff to ask more questions and discuss
how to go about the treatment without any danger of confusing the patient. The information
discussed during handover between the staff, can be very upsetting for a patient and have
negative effects on her or his clinical status. It was agreed by the senior physicians that it is
important to focus completely on the patient when communicating with them. The respective
information should be focused on what is important for the patient to know and should be
transferred in an understandable manner.
The table below illustrates the specific information to be handed over and tasks each
profession has during rounds. The consultant will then be the main person talking to and
discussing further steps with the patient. In addition to these tasks, an extra employee will be
responsible to organize relocations and transfer of the patients to other wards. They give
information about where vacant beds are available and where patients could be relocated to.
The physicians then also define demands, as to where to the patients should be best relocated.
Needless to say, these patients have already been treated in the ED and are now stable
enough for a relocation to another hospital ward.
17
Table 2: ID-PHONE Protocol for medical rounds during handover
MEDICAL ROUNDS PROTOCOL
Resident Nursing Personnel Consultant
Communication with the patient
ID IDENTIFICATION
Name, Age Name Name Introduction
P ACUTE PROBLEM
main symptom, working diagnosis, measures
taken
domestic situation, compliance,
communication / mobility, isolation,
surveillance
main diagnosis, what should be treated
topic, main diagnosis, consequence
H PAST MEDICAL HISTORY
allergies, known illnesses,
general practitioner or medical specialist
treating patient
allergies, situation at home,
living will, caretaker Questions?
explain, motivate, repeat, mirror, sum
everything up
O OBJECTIVE DATA
A-B-C-D-E, lab values,
imaging / dynamics
A-B-C-D-E, vital signs,
diagnostic findings Questions?
what was reached / tested? what is still
missing?
N NEXT STEPS
treatment plan, missing tests,
tasks for nursing personnel or secretary
Tasks for doctors or secretary
notes about treatment plan and tasks
what is going to happen next? explain
invasive treatment, new / different
medication
E DISCHARGE/ NEXT STEPS
suggestions, goals, reasons for delay
suggestions, goals, reasons for delay
summary and final decision, taking ethics
into account
when / where / how, Information for
relatives, debriefing outside of
patient room
Separate columns and rows are used for each profession and according task.
For the handover between EMS and ED ward, it was taken into account that the ABCDE
scheme is an established part of primary care. To enable its further usage, the ABCDE scheme
was integrated completely into the ID-S2A2MPLE-protocol. This new protocol was intended
mainly for the use of the ED staff themselves, but it was also expected of the ambulance staff
to do their handover according to the protocol. Posters hung in the handover area with the
specific protocol scheme portrayed made this achievable. It contained the following information
structure:
18
Table 3: ID-S2A2MPLE mnemonic
Mnemonic Meaning of mnemonic Further explanation
ID Identification of patient,
Time and date of admission,
Team
By team, the EMS team which transferred the patient is meant
S₂ Situation In which the patient was found
Symptoms
A₂ ABCDE Standard mnemonic by which the patient’s parameters are obtained in the field
Allergies
M Medication Standard medication of patient, as well as already applied by EMS
P Patient History
L Last meal
E Exploration Information about family doctor, social anamnesis, relatives, home address, living will, etc.
In the end, this scheme was used as a shared understanding aid for EMS- and ED-staff, whilst
the admission was noted done on the ID-PHONE mnemonic. Since most of the work and
information transfer within the ED was structured through the ID-PHONE, it turned out to be
more complicated and time consuming using two different forms of written mnemonics. Since
the ID-S2A2MPLE-mnemonic is hung out on posters in the handover area, ambulance staff can
use it as an aid for structuring their handover.
2.2.2. Survey Questionnaires
The surveys consisted of questionnaires divided into two sections. The first section asked for
a rating of the importance of given items. In the second section, the personal satisfaction with
the respective items was prompted for. The main focus was put on the satisfaction ratings and
their respective change after the implementation of standardized handover protocols.
Importance ratings were obtained for different reasons: It was of interest whether these also
changed through a new protocol and, most importantly, through staff training in communication
and through better communication also stress reduction. Avoiding an integration of satisfaction
ratings of participants, who did not care about certain items, was also achieved through this.
19
This resulted in a more robust, statistical analysis. All questionnaires were handed out to the
ED staff, patients and EMS staff and collected after the completion. Forms which were not
filled out completely were only used if more than half of the questions were answered.
2.2.3. Questionnaires for emergency medical services
The first phase of surveying the EMS took place at the beginning of 2015. In this first phase,
the satisfaction with the already existing ABCDE scheme was evaluated.
One goal of the survey was to evaluate where, according to EMS and ED staff, shortcomings
in the handover process existed. The main goal of survey was to examine the impact the
implementation of the new handover had on its process. Information was sent out to the
different EMS operating in the Freiburg region. These were the German Red Cross (DRK), the
Malteser, the Johanniter and the German Air rescue (DRF). They were informed that the
survey would take place in the ED of the University Hospital of Freiburg and asked to hand this
information on to their fellow colleagues. The questionnaires were given out to the EMS, upon
arrival in the ED ward, together with the admission files for the respective patient. This was
done by the central admission desk of the ED. They were told that the questionnaires were to
be filled out directly after the handover by one of the EMS staff members and returned to the
admission desk. To understand where and how handovers take place, the following flow chart
depicts the proceedings of an emergency case in the UNZ of Freiburg:
20
Figure 1: Workflow from preclinical assessment of the patient to his or her discharge from the emergency department of the University Hospital of Freiburg
21
In the first two weeks of the survey, a person responsible for the survey was present at the
admission desk for several hours per day and helped explain the purpose of the survey, as
well as answer questions regarding the questionnaire. For the most part, these were filled out
thoroughly and diligently. Those which were only filled out by 50% or less were excluded out
of the analysis. The questions which could be answered on an ordinal scale were analysed
statistically, while all other answers (e.g. team allegiance, type of admission, references to time
and date, etc.) as well as written comments, were analysed qualitatively. The questionnaire
(which can be found in German language in the Appendix), comprised following items:
1. General information about date, check-in/-out time, EMS-organisation (DRK, DRF,
Malteser, Johanniter) as well as respective team member (emergency doctor,
emergency assistant, paramedic, rescue worker) allegiance
2. Estimated duration of time from arrival until the handover
3. Was the patient announced by the EMS in advance upon arrival at the ED?
4. Handover information complete? (With the possibility of listing things, which were
forgotten)
5. Estimated duration of handover
6. Medical quality of patient care (With the suspected diagnosis)
7. Completeness of the team (Who was attending? Nurse present? Physician present?)
8. Collegial atmosphere during handover
9. Standardized handover protocol used in the field (e.g. ABCDE)
10. Handover took place without interruption
11. Satisfaction with today’s handover
12. Other comments
For each item, the EMS were asked to determine how important they found these and how
satisfied they were with them. This only concerned the handover they had just given.
Furthermore, space was given for comments about each item. The survey period took place
between mid-April to mid-May 2015, where 93 questionnaires were answered, returned and
analysed. Shortly after this, in mid-June, the ID-S2A2MPLE was implemented. It was sent out
to the different EMS offices to be handed out to their staff. In the Emergency ward the protocol
was also distributed and posters with the ID-S2A2MPLE protocol were hung out in the area
where handover took place.
The ED staff, as well as the EMS, were continuously asked to work along the lines of this
handover scheme. After the implementation period, more time was given for the protocol to
fully establish itself until the second survey was conducted in Mid-March to mid-April of the
22
year 2017. Here the same questionnaires were used: 79 were completed, returned and
analysed.
The comments that were given in written form were not analysed statistically, but taken into
consideration when optimizing the working and handover conditions in the ED.
2.2.4. Questionnaires for patients
During the same time period as the first survey for the EMS was being conducted, a new
protocol for handover from EMS to ED and for handovers during ward rounds was
implemented. Here, an accompanying questionnaire was handed out to patients as well as ED
staff. The patient questionnaire was constructed to analyse what is important for a satisfactory
stay in the ED, as well as compare satisfaction ratings before and after the implementation of
a standardized protocol for handover during rounds. The items the patients were asked about
are listed below:
1. Waiting time until first contact with the attending staff
2. Information given about waiting time
3. Explanations are understandable
4. Opportunity for questions is given
5. Integration of patient's reference person
6. Explanations about the next steps
7. Information about expected length of stay
8. Professional competence of physician
9. Understandable explanations of given medication
10. Physician greets patient personally
11. Relaxed atmosphere during rounds
12. Patient has the possibilty to report about his/her illness
13. Staff is being responsive to patient's fears
14. Enough time for patients to talk
All patients who were capable to fill out the form themselves or with the help of a third party
were included into the survey. If help was needed out of physical reasons, either a relative or
close acquaintance was asked to assist. Otherwise the survey conducting person, or a
voluntary social worker, who was not an employee of the ED, helped out. Patients who were
not able to communicate or were cognitively impaired to the extent that they could not follow
or answer the questions, were excluded out of the questionnaire. Patients were seen as
cognitively impaired, who suffered severe injuries, were in strong pain, a status of deliration,
intoxicated or were in another severe medical condition and could not react to questioning or
refused to take part. It was emphasized that all questionnaires were going to be analysed
23
anonymously and that they would have no influence on their respective treatment. Whenever
possible, patients were asked to fill out the form themselves with the intention to avoid
interviewing biases. The same concept was applied to the first and the second round of
questioning in March- April 2015 and June 2016 respectively. In the first round, 92 answered
questionnaires were analysed, while in the second round 40 questionnaires were used.
The surveys were anonymized and analysed thereafter. Comments were analysed
qualitatively and taken into account for optimizing the conditions and patient communication in
the ED. Furthermore, the surveys were used to create the new ID-PHONE handover scheme
and set the focus of the staff training, which was conducted parallel to its implementation. Thus,
it was possible to show the ED staff both the specific weaknesses and strengths of the Freiburg
Emergency Department, as well as optimize the new handover protocol. The conduction of a
focused training, with the strengths and weaknesses in mind, was carried out. Furthermore,
the most important results were collected to create a poster that was displayed in the ED, along
with the poster of the new ID-PHONE handover protocol. Through this, all staff members were
and are able to retrace the study and its results. Although the ID-PHONE handover scheme
was constructed in this specific setting, it was meant as a universal emergency ward handover
protocol and created to be applicable in other emergency department settings beyond
Freiburg, as well.
2.2.5. Questionnaires for ED staff
Since the ED staff is involved in all the handovers, two kinds of questionnaires were handed
out to them. The first one concerned the handover from EMS to ED, and the second one
concerned patient care and communication. Furthermore, resources for dealing with stress
were accounted for.
The questionnaire concerning the quality and completeness of the EMS handover was only
conducted in the first survey round. The reason being that this questionnaire was supposed to
be filled out directly after the handover from the EMS to ED, in order to collect reliable data.
This was not possible or done most of the time, because of elevated patient admissions and
the resulting high stress level. Staff then often postponed the answering of the form, which
resulted in forms not being thoroughly filled out and unreliable. Therefore, no second survey
round was performed, since pre- to post-intervention comparison could not be drawn.
Nevertheless 29 survey forms were filled out and analysed before the intervention. They were
not used in training or protocol construction though.
The second questionnaire for the ED-staff concerned patient communication and treatment,
as well as stress factors and tools for coping with these. The questions concerning patient
contact were identical to those posed to the patients themselves. The staff was asked to put
24
themselves into the position of the patients and then answer the questions accordingly,
meaning that doctors as well as nursing personnel were supposed to rate their own work, by
estimating how satisfied patients were with it. The importance ratings of these items, were also
supposed to be given as an estimation of the patient’s view. Since these questions were
identical to those the patients were asked, a direct comparison could be drawn. This means
that differences between the estimations of the staff and the actual ratings of the patients could
be statistically analysed. The statistical analysis was done between the two groups (Patients
vs ED staff), as well as within the groups over time.
The second part of the questionnaire concerned factors, which contributed to stress in the
working culture. It investigated, whether techniques to deal with this stress were known to the
staff. Changes in these parameters were only comparable over time within the group of ED
personnel. The reason for collecting this data, was to survey the subjective stress levels of the
emergency department which, in theory, should have a significant influence on the satisfaction
with their work and workplace (Ratanawongsa et al. 2012, p. 1635; Lu et al. 2015; Goldberg
et al. 1996). The data was then used to specify and personalize the handover and patient
communication training and to put a focus on how these newly acquired tools can be used to
reduce stress. Important elements in the survey were the questions concerning the
communication with colleagues, residents and patients. Further intentions were to find out
whether the daily procedures were known to everyone and successfully put into use. The
survey items consisted out of statements (e.g. the communication with patients poses no
challenge for me) and answers were again given on an ordinal scale. This scale ranged from
“1=No, I disagree” to “4=Yes, I completely agree with this statement”. The same survey was
conducted half a year after the training and differences in self-estimation were analysed.
Before the training, in June 2015, 25 survey forms were answered, while afterwards, in January
2016, 16 could be could be used for further analysis. These were also kept completely
anonymous. Only the respective employment position was revealed. Content of survey about
communication and stress coping mechanisms can be found in the appendix: Table 7: English
translation of the ED-staff questionnaire concerning stress management techniques and
patient treatment.
2.3. Training and implementation of the new protocols
The training was conceptualized primarily for doctoral as well as nursing personnel from the
Freiburg University Emergency Department. In the first round the permanently employed
doctors, as well as the ward manager and co-manager were schooled. They were supposed
to become multipliers, passing on their knowledge to the nursing staff and rotating doctors.
Later, another hour of schooling for some of the nurses took place and further similar sessions
25
were intended. It was conducted in a cooperation with an external trainer, namely Harald
Seidler from “Flow promotions”. Next to presenting the results of the surveys, communication
skills and the new ID-PHONE protocol were presented and explained. Through the input of the
participants, the protocol was adjusted and thereafter put into practice. The participants were
asked to give direct feedback about the success of the implementation and improvement
suggestions were welcomed. These suggestions and comments were subsequently used to
optimize the handover procedure and protocol.
A focus was put on communication techniques and how to reduce stress and misunderstanding
through these. The participants recognized the importance and relevance of different
communication levels (verbal vs. non-verbal) and expressed a necessity for regular schoolings
about communication skills. Two further schoolings for new incoming staff were performed.
These lasted approximately one hour.
26
3. Results
The results of the survey were analysed through statistical analyses and are presented below.
The statistical analysis was performed with IBM SPSS Statistics 24 ©. Because the tested
variables were ordinal scaled, non-parametric tests were used for the analysis. Standard
distribution of all variables was checked and confirmed with the Kolmogorov Smirnov Z-test. A
comparison of the mean values was conducted with the Mann-Whitney U-Test for independent
samples. All four conditions for this test were met3. The samples were defined as independent,
since the patient and staff collective were not identical in the different surveying timeslots. The
influence of the ID-PHONE Protocol was obtained through analysing patient and ED staff
satisfaction before and after the implementation. The influence of the ID-S2A2MPLE scheme
was obtained through the difference in the EMS surveys.
The Data was coded on an ordinal scale from one to four, with following allocations:
1=unimportant/ unsatisfied, 2=less important/less satisfied, 3=rather important/rather satisfied,
4=very important/very satisfied. When calculating the means of the single items, an
approximate of the overall importance or satisfaction in the respective survey group can be
given. This can be done through locating the mean on a continuum of the rating scale.
Since Data was collected before and after the intervention, a comparison will be drawn. “Pre-
intervention” will be abbreviated by “pre” and “post-intervention” by “post”. Furthermore, the
satisfaction ratings were analysed twice: Once including all data collected, and once correcting
for the importance ratings. The latter included only cases in which respondents rated the
respective item as either rather or very important, which corresponds to either a 3 or 4 on the
ordinal scale. This is labelled by: “For all cases, if importance>2”. Whenever an important
difference in the satisfaction ratings can be found, because of varying importance ratings, the
numbers, corrected for importance are used in the analysis.
3.1. Emergency medical service
The staff of the EMS were altogether quite satisfied with the handover process in the ED of the
University Hospital of Freiburg (UNZ). In the survey ahead of the implementation of the new
protocol, they were most satisfied with the collegial atmosphere (mean: 3.68, SD:0.546, N=80)
and least satisfied with the standardized handover (mean:3.17, SD:0.703, N=64). They also
voted a standardized protocol as least important (mean:2.89, SD:0.786, N=82). Even when
3 Fulfilled conditions, in order to be able to use the Mann-Whitney U-test are the following: All the observations from both groups were independent of each other, the responses are coded on an ordinal scale from 1 to 4, under the null hypothesis H0, the distributions of both populations are equal and under the alternative hypothesis H1 distributions are not equal.
27
correcting for the importance rating of standardized protocols, EMS staff were least satisfied
with them before the new protocol implementation (mean:3.26, SD:0.693, N=43). The things
rated most important by the EMS staff were that the data they handed over was complete
(mean:3.62, SD:0.584, N=79) and that the team receiving the handover was complete
(mean:3.63, SD:0.601, N=81). A team is complete when the nurse looking after the patient
post-admission and the attending physicians are present. In a stressful and overrun ED, it can
easily happen that one of these persons are not present at handover. In the UNZ, this rarely
happens though, which can also be seen in the high satisfaction ratings of the EMS staff and
the percentage of times a nurse and doctor were present at handover (pre-intervention (pre):
mean:3.48, SD:0.833, N=69; post-intervention (post): mean:3.41, SD:0.79, N=73; p=0.415).
Before the intervention, a doctor was present in 85%, a nurse in 86% of the time. After the
intervention in 85% of the handovers a physician was present and 88% a nurse. Doctor and
nurse being present at the same was the case in about 75% of the time. The importance rating
for this item stayed about the same in both time slots.
Interestingly, not being interrupted during handover became the most important item after the
intervention (mean:3.7, SD:0.485, N= 87). The satisfaction ratings for this is one of the lowest
(For all cases, if importance>2: mean:3.38, SD:0.781, N=71). The collegial atmosphere has
become significantly less satisfying after the intervention (pre: mean:3.68, SD:0.546, N=80;
post: mean:3.44, SD:0.61, N=71; p=0.016). Importance ratings did not change much (pre:
mean:3.56, SD:0.583, N=89; post: mean:3.53, SD:0.644, N=87; p=0.851) and even when
correcting for importance, the statistical significance for the satisfaction stayed the same. This
is not the effect we had expected after communication training. On the other hand, using a
standardized protocol has become significantly more important after the implementation of the
new standardized protocol (pre: mean:2.89, SD:0.786, N=82; post: mean:3.17, SD:0.804,
N=84; p=0.021). Satisfaction with using standardized protocols shrunk, but not to a statistical
significant level (For all cases if importance>2: pre: mean:3.26, SD:0.693, N=43; post:
mean:3.13, SD:0.793, N=52; p=0.515). Altogether, only 70.8 % even rated standardized
protocols as rather or very important before the handover. This rose to 79.8 % after the
handover (p=0.21).
The estimated time, the EMS had to wait until handover rose from 2 mins 47 secs to 3 mins
55 secs. Interestingly, despite these estimations, satisfaction with waiting time also rose,
though not statistically significant (for all cases if importance>2: pre: mean:3.42, SD:0.765, N=
78; post: mean:3.53, SD:0.711, N=80, p=0.355). Also, the estimated handover time has risen
from 2 mins 58 secs to 3 mins 31 secs. Here, the importance rose significantly (pre: mean:
3.22, SD:0.754, N=77; post: mean:3.49, SD:0.631, N=70; p=0.029), while satisfaction with this
shrunk (pre: mean:3.54, SD:0.604, N=72; post: mean:3.45, SD:0.814, N=69, p=0.864). The
28
overall estimated time spent in the UNZ stayed the same though, at 13 mins. All these numbers
are only estimated and can therefore not be relied upon.
Overall, a trend towards less satisfaction for all items, except for waiting time until handover
and completeness of handed-over data, is observed when not correcting for importance
ratings. If only respondents who rated the respective items as rather or very important are
included, a trend towards more satisfaction can be seen for waiting time until handover,
feasibility of patient registration in advance at the admission desk, completeness of handed-
over data and the overall satisfaction with todays handover. None of these trends are
statistically significant.
29
Figure 2: Mean importance rated by Paramedics from the Ambulance Services, pre-and post-intervention
Mean importance rated by Paramedics from the Ambulance Services, pre-and post-implementation of the standardized protocols (pre=2015; post=2017). The scale is ranging from 1= “not important”, 2= ”less important”, 3= ”quite important” to 4= ”very important”. Error bars represent the standard deviation of the mean. N(pre)= 86, N(post)= 87. Statistically significant differences are marked: *=p<0.05.
30
Figure 3: Mean satisfaction rated by Paramedics from the Ambulance Services, pre-and post-intervention, corrected for importance
Mean satisfaction rated by Paramedics from the Ambulance Services, pre-and post-implementation of the standardized protocols (pre=2015; post=2017), corrected for importance: If importance was rated quite or very important, it had a value of >2. Only satisfaction ratings of respondents, rating the respective items as important were included. The scale is ranging from 1= “not satisfied”, 2= “less satisfied”, 3= “quite satisfied” to 4= “very satisfied”. Error bars represent the standard deviation of the mean. N(pre)= 86, N(post)= 87. Statistically significant differences are marked: *=p<0.05.
31
The staff of the UNZ were less satisfied than the emergency medical service (EMS) with the
completeness of the team (mean:3.30, SD:0.912, N=27) and the collegial atmosphere
(mean:3.57, SD:0.573, N=28), before the intervention. They rated the quality of the respective
handovers with a mean of 3.32 (SD 0.772, N=28), which means they were rather satisfied with
the quality. According to the ED-staff, before the intervention, a physician was present during
the entire handover 89% of the time. Only half of the time the EMS protocols were used during
the following treatment in the ED, and in 15% a seamless treatment was not possible due to
missing data. According to the answers of the questionnaire, no incidents occurred where a
patient experienced an adverse event because of missing data.4 No data post-intervention was
obtained.
Figure 4: Importance and satisfaction ratings of handover from EMS to ED, rated by ED-staff
Mean importance and satisfaction rated by staff from the emergency department, pre-implementation of the standardized protocols (t=04/2015). The scale is ranging from 1= “not important/satisfied”, 2= “less important/satisfied”, 3= “quite important/satisfied” to 4= “very important/satisfied”. Error bars represent the standard deviation of the mean. N=26.
The following table displays the different ambulance operators which deliver patients to the
ED.
4 Adverse events can be defined as unwanted incidents, caused by healthcare management, which resulted in a prolonged hospitalization, new disability or death. Rafter et al. 2015
32
Table 4: Number of Ambulance Operators, who filled out the questionnaire during both survey periods. A disclosure was only given in half of the questionnaires.
Ambulance Service Organisation Number of questionnaires answered (this allows an approximate of times, they delivered patients to the UNZ during the survey phase)
DRK (Deutsches Rotes Kreuz) 55
Malteser 23
Johanniter 2
DRF (Deutsche Luftrettung) 12
3.2. Patient and ED-staff
Since patients and ED-staff received a similar questionnaire, some of the responses can be
easily compared. The part of the questionnaire, which was identical for both groups, was
analysed in direct comparison. Question items which were not identical, were analysed
independently.
In general, patients were already quite (45.6%) or very (48.9%) satisfied with the work of the
ED-staff before the intervention. This means that altogether 95% of the patients were satisfied.
The intervention that followed was a communication training and explanation of the new inter-
shift handover procedure for ED-staff, which also pays special attention to the communication
with the patient. Thereafter, the overall patient satisfaction rose to 97.5%. Considering that the
satisfaction ratings were already very high, this was rather surprising. 59% were very satisfied
and 38.5% quite satisfied with their stay and treatment by the end of 2016.
The least satisfied patients were those, who had been in the emergency ward for 4-6 hours.
This accounts especially for information about the waiting time, where 33% were not satisfied,
and information about the estimated length of stay, where 40% were not satisfied. Also,
information about the next steps becomes increasingly important with time spent in the ED, as
patients become increasingly less satisfied with this information. This is observed before as
well as after the intervention. As shown in Figure 5, information about the next steps given
from ED staff was one of the most important items for patients (pre: mean: 3.76, SD: 0.455,
N=88; post: mean: 3.9, SD: 0.307, N=39; p=0.096). Most important was the expertise of the
physician (pre: mean: 3.93, SD: 0.255, N=90; post: mean: 3.92, SD: 0.273, N=38, p=0.843),
followed by the comprehensibility of the explanations (pre: mean: 3.90, SD: 0.300, N= 91; post:
mean: 3.88, SD:0.335, N=40; p=0.657). These three parameters remained the most important
33
ones for patients throughout. As expected, most importance ratings of the questioned
parameters did not change significantly (see Figure 5). We did not expect a change of the
importance ranking of patients due to an intervention within the ED, since they did not take
part in the changing process and the patient collectives were completely independent from
each other. Surprisingly one item changed significantly (p=0.032): The importance rating of
being given the opportunity for questions rose from 3.63 (SD: 0.532, N= 87) to 3.84 (SD: 0.37,
N=38). This needs to be controlled for, in the analysis of the satisfaction ratings.
34
Figure 5: Mean importance rated by patients and emergency department staff pre-and post-intervention
Mean importance rated by patients and emergency department staff pre-and post-implementation of the standardized protocols (pre=2015; post=2016/2017). The scale is ranging from 1= “not important”, 2= “less important”, 3= “quite important” to 4= “very important”. Error bars represent the standard deviation of the mean. The range of the number of respondents (N) results from the fact that not all the items were answered by all of the respondents. Statistically significant differences are marked: *=p<0.05.
35
We expected to observe an influence of the intervention on the satisfaction ratings of patients.
A trend towards more satisfaction was observed in all questioned parameters, although without
achieving any statistical significance. The satisfaction with the two most important items
(professional competence of the doctor and that explanations are understandable) was quite
high, both before and after the intervention: 94% were very or quite satisfied with the
comprehensibility of the explanations given by the staff before the intervention in 2015 (N=84)
and 97.8% afterwards in 2016 (N= 39; p=0.612). The ratings for professional doctoral
competence were quite similar, 97.3% (N=87) before and 97.1% (N=38) after the intervention
stated to be satisfied with this (p=0.583). In both time slots these were one of the three
parameters they were most satisfied with. This means that the items most important for
patients were also rated most satisfying. This cannot be said for information about the next
steps. It was rated as the third most important item, but satisfaction ratings were moderate,
compared to the other items.
Figure 6: Comparison of satisfaction ratings of the three most important items rated by patients
Pre- (N= 58-80) and post- (N=32-40) implementation of the ID-Phone Protocol (pre=2015; post=2017). Numbers are noted in rounded percentages. No statistical significance was found, differences in percentages can be seen as trends. The range of the number of respondents (N) results from the fact that not all the items were answered by all of the respondents.
36
Before the communication training, the ED staff thought the importance of understandable
explanations to be significantly lower than rated by patients (ED-staff: mean:3.63, SD:0.5,
N=24; patients: mean:3.9, SD:0.3, N=91; p=0.001). This was not observed for the second
survey round, here ED staff rated understandable explanations more important than before
(ED-staff: mean:3.73, SD:0.46, N=15; patients: mean:3.88, SD:0.34, N=40; p=0.21).
Table 5: Importance ratings, comparing ED staff and patients, pre- and post-intervention Table is illustrating the mean, Standard Deviation (SD) and Number (N) of the respondents of the questionnaire. Pre-intervention (t=1): 04/2015. Post-intervention (t=2): 2016/2017.
Importance Ratings
Pre-intervention (t=1) Post-intervention (t=2)
Patients ED- staff
Patients ED-staff
Mean (SD)
N Mean (SD)
N Mean (SD)
N Mean (SD)
N
Waiting time until first contact
3.58 (0.56)
90 3.71 (0.46)
24 3.45 (0.60)
40 3.53 (0.64)
15
Information given about waiting time
3.29 (0.72)
80 3.67 (0.48)
24 3.18 (0.80)
38 3.8 (0.41)
15
Explanations are understandable
3.9 (0.3)
91 3.63 (0.5)
24 3.88 (0.34)
40 3.73 (0.46)
15
Opportunity for questions given
3.63 (0.53)
87 3.42 (0.65)
24 3.84 (0.37)
38 3.73 (0.46)
15
Integration of patient's reference person
3.42 (0.81)
79 3.13 (0.76)
23 3.39 (0.75)
33 3.14 (0.77)
14
Explanations about the next steps
3.76 (0.46)
88 3.42 (0.65)
24 3.9 (0.31)
39 3.57 (0.51)
14
Information about expected length of stay
3.43 (0.69)
88 3.46 (0.72)
24 3.5 (0.83)
38 3.38 (0.65)
13
Professional competence of doctor
3.93 (0.26)
87 3.48 (0.59)
23 3.93 (0.27)
38 3.21 (0.8)
14
Understandable explanations of given medication
3.6 (0.57)
78 2.54 (0.88)
24 3.74 (0.51)
35 2.86 (1.03)
14
Doctor greets patient personally
3.31 (0.76)
90 3.5 (0.59)
24 3.18 (0.8)
38 3.53 (0.83)
15
Relaxed atmosphere during rounds
3.47 (0.61)
88 3 (0.59)
24 3.55 (0.65)
38 3.27 (0.59)
15
Patient has the possibilty to report about his/her illness
3.38 (0.73)
91 3.42 (0.65)
24 3.53 (0.69)
38 3.47 (0.64)
15
Staff is being responsive to patient's fears
3.37 (0.77)
90 3.21 (0.72)
24 3.47 (0.74)
36 3.73 (0.46)
15
Enough time for patients to talk
3.7 (0.49)
90 3.5 (0.66)
24 3.74 (0.45)
38 3.8 (0.41)
15
37
As seen in Table 5, Explanations about medication was rated least important by doctors as
well as by nurses at both surveying times (mean:2.66, SD:0.94; N=38 pre-and post-
intervention combined), whereas patients did find this very important (mean:3.65, SD:0.55,
N=113 pre-and post-intervention combined). It was one of the three parameters they were
least satisfied with: 15.2% said they were either less or unsatisfied. Figure 7 shows that less
than half of the patients were very satisfied. This changed after the intervention: 62.5% rated
the explanations about medication very satisfying in 2016 and only 9.4% were either less or
unsatisfied (p=0.117). Though the staff of the UNZ thought information about waiting time to
be significantly more important than the patients did (p=0.020), it was the parameter patients
were least satisfied with (pre: mean:3.29, SD:0.72, N=80; post: mean:3.18, SD:0.8, N=38;
p=0.736). The staff members did however, correctly rate information about waiting time as one
of the parameters they perceived patients to be least satisfied with. Additionally, Information
about duration of stay in the ED was rated dissatisfying by patients (pre: mean:3.43, SD:0.69,
N=88; post: mean:3.5, SD:0.83, N=38, p=0.526) (see below in Figure 8).
Figure 7: Comparison of satisfaction ratings of the three items rated by patients as most unsatisfying
Pre- (N= 58-80) and post- (N=32-40) implementation of the ID-Phone Protocol (pre=2015; post=2017). Numbers are noted in rounded percentages. No statistical significance can be, differences in percentages can be seen as trends. The range of the number of respondents (N) results from the fact that not all the items were answered by all of the respondents.
38
In these items a trend towards more satisfaction can be seen. This can also be said for all
other questioned items and the general satisfaction of the patients with their treatment. The
general high levels of satisfaction are particularly interesting, because the ED-staff themselves
perceived patients to be significantly less satisfied than what was found through the survey. In
every single item ED-staff rated patients to be less satisfied, than they actually were. This trend
was consistent for both surveying times, with the lone exception being the question about the
professional competence of the doctor. The professional competence of the physician was
rated with a mean of 3.66 (SD:0.53, N=74) pre-intervention and with a mean of 3.71 (SD:0.52,
N=35) post-intervention (p=0.583). This shows patients to be very satisfied with the
competence of their attending doctor. This was also the item, the ED-staff were most satisfied
with themselves (pre: mean:2.96, SD:0.56, N=23; post: mean:3.42, SD:0.67, N=12; p=0.068).
A statistical difference between the patient’s and ED-staff satisfaction ratings was observed
only before the intervention (p=0.000). After the intervention, no statistical difference in the
satisfaction rating with the professional competence of the attending doctor can be found
(p=0.116). In all other items, the ED-staff is significantly less satisfied with their work and the
treatment of the patients, than the patients themselves are (p<0.05). This is true for both
timepoints, before and after the intervention.
The parameter patients were most satisfied with was the personal greeting by the doctor in
charge (pre: mean:3.69, SD:0.54, N=80; post: mean:3.84, SD:0.37, N=38; p=0.145). This was
followed by the professional competence of the doctor (numbers mentioned above) in charge
and the understandability of the given explanations (pre: mean:2.6, SD:0.6, N=84; post:
mean:3.67, SD:0.53; N=39; p=0.612). This chronological order of most satisfying items stayed
the same for both points in time. For more information see below Figure 8. Before the
intervention, ED-staff was also most satisfied with the personal greeting by the doctor in charge
(mean:3.14, SD:0.71, N=22), followed by professional competence of the doctor (numbers
mentioned above) and that the patient has the possibility to talk about his/her illness (mean:2.8,
SD:0.616, N=20). After the intervention this changed to a small degree: the professional
competence of the doctor becomes the most satisfying item (numbers above) followed by the
personal greeting (mean:3.23, SD:0.725, N=13) and that explanations are understandable
(mean:2.77, SD:0.832, N=13).
A very interesting phenomenon is that the satisfaction of the staff with a relaxed atmosphere
during rounds decreased significantly (pre: mean:2.45, SD:0.67, N=22; post: mean:1.85,
SD:0.56, N=13; p=0.022). This was the only item that showed a significant change after the
intervention for the satisfaction ratings and the one they were least satisfied with in the second
questionnaire round. Furthermore, patients did not become less but rather more satisfied with
this (pre: mean:3.46, SD:0.693, N=80; post: mean:3.62, SD:0.633, N=39; p=0.205).
39
In general, the staff of the UNZ perceive patients to be less satisfied with their work than they
are. Before the training and new communication guidelines, only 9.5% thought that patients
were very satisfied in all 14 Items and 49.3% thought they were quite satisfied before the
intervention. This means that about 40% of the staff believed patients not to be satisfied with
the work of the ED. In 2016, this did not change much, 12% believed patients to be very
satisfied while 44.8% thought they were quite satisfied.
40
Figure 8: Mean satisfaction rated by patients and emergency department staff pre-and post-intervention
Mean satisfaction rated by patients and emergency department staff pre-and post-implementation of the standardized protocols and staff training (pre=2015; post=2016/2017). The scale is ranging from 1= “not satisfied”, 2= “less satisfied”, 3= “quite satisfied” to 4= “very satisfied”. Error bars represent the standard deviation of the mean. The range of the number of respondents (N) results from the fact that not all the items were answered by all of the respondents. Statistical significant differences are marked: *=p<0.05.
41
3.3. Stress coping and communication mechanisms
Although more than half of the staff stated that they were somewhat familiar with
communication and stress reduction techniques before the training, 40% did not know or use
techniques to cope with stress (see Table 6: Perception and use of stress management
and communication techniques by ED-staff). After the training, 80% of the staff felt confident
in stress reduction techniques. This leaves only 20% which did not know or use these
techniques confidently. Also, techniques for communication were better known to the staff after
the training.
According to the staff, ward rounds became better structured and the structure known to all.
The percentage of staff who completely agreed with this rose from 12.5% before the new
handover, to 26.7% afterwards. Furthermore, the nursing staff received a better-defined role
during handovers, which enabled them to bring in important information about the patient (see
Table 6: Perception and use of stress management and communication techniques by
ED-staff). Less respondents thought that handover or discharge of patients followed a known,
written documentation. Also, less staff knew which information patients need for a successful
discharge and treatment at home (92% knew what was needed beforehand, 73.3%
afterwards).
23 of 25 respondents believed that the information transferred during rounds was very much
dependent of which doctor was doing the rounds. This did not change after the training and
handover protocol introduction, however. Also, all of the post-intervention questioned
personnel believed that the transfer of information is strongly dependent on the person,
handing over.
Structured, written protocols were used in 30% of the time before the implementation of the
new protocol. Three months after the training, written protocols were used in 43% of the time.
Fortunately, after the intervention 73.3% of the staff felt that patients have the possibility to talk
about their experience of their disease, compared to 60.8% beforehand. This could potentially
be a result of an increased focus on, and improved communication with the patient. In 80% of
the cases, the patient and her or his well-being, was the centre of attention during ward rounds.
17.5% more cases than in 2015. It should be noted that all these results should be
acknowledged as general trends, as none showed a statistical significance (p>0.05).
42
Table 6: Perception and use of stress management and communication techniques by ED-staff
Share of ED staff, who rated the listed items according as to how often they applied for in their personal reality. Share is given in percentages of the total numbers. Separated by the surveying times: T=1: 04/2017, T=2: 10/2016. Respondent numbers being N(t=1)= 26 and N(t=2)= 15.
Perception and use of stress management and communication techniques by ED-staff
True True most of the time
True less often Not true
I know and use communicative techniques, which help to communicate effectively with the patient
T=1 20% 60% 20% 0%
T=2 26.7% 60% 13.3% 0%
I know and use communicative techniques, which help to communicate effectively with my team and supervisor
T=1 16% 56% 24% 4%
T=2
26.7% 53.3% 20% 0%
I know and use deliberatively techniques, which help me to cope with stress
T=1 20% 40% 36% 4%
T=2 35.7% 35.7% 28.6% 0%
The procedure and involvement of patients during the ward rounds is strongly dependent on the round-leading physician
T=1 58.3% 33.3% 8.3% 0%
T=2 80% 20% 0% 0%
Ward rounds are clearly structured. This structure is known to all people involved and everyone has a defined responsibility
T=1 12.5% 50% 20.8% 16.7%
T=2
26.7% 46.7% 13.3% 13.3%
During ward rounds, the patient is the centre of attention and her or his well-being is elevated through communication
T=1 12.5% 50% 25% 12.5%
T=2 6.7% 73.3% 13.3% 6.7%
The nursing staff have a set, clearly defined role at every ward round and bring in important information about the patient
T=1 8.3% 37.5% 37.5% 16.7%
T=2
13.3% 60% 13.3% 13.3%
The patient is given the opportunity to report about her or his personal experience of the illness
T=1 13% 47.8% 21.7% 17.4%
T=2 20% 53.3% 13.3% 13.3%
43
The handover follows a known, written documented procedure
T=1 4% 28% 44% 24%
T=2 0% 46.7% 20% 33.3%
During the handover of patients, the transfer of information is strongly dependent on the person, handing over
T=1 52% 32% 12% 4%
T=2 66.7% 33.3% 0% 0%
The discharge of patients follows a known, written documentation
T=1 20% 44% 28% 8%
T=2 13.3% 26.7% 40% 20%
I know, which information patients need for a successful discharge to their home and make sure that these are transferred
T=1 32% 60% 0% 8%
T=2 33.3% 40% 20% 6.7%
44
4. Discussion
The literature highlights the importance of structured handovers for patient safety, shared
understanding, stress reduction and greater staff- as well as patient satisfaction. Our results
show a more diverse picture. They show that patient satisfaction is generally elevated through
standardized handover protocols and procedures. This general trend cannot be seen in staff
satisfaction. Training is of major importance to successfully implement a new handover
scheme, which is accepted by the staff. Furthermore, a substantial misjudgement on the part
of the ED-staff was found, concerning what they believed patients to be of importance. We
collected information about the importance and satisfaction of staff and patients. This allows
us to take up subjective opinions and feelings of the affected individuals. We were not able to
collect objective data on patient safety or the like. This section discusses the implications of
these results, shortcomings of this survey and indications for further research. Since we
performed two interventions, at two different check-points, with two different mnemonics, the
results of these are also discussed separately.
4.1. New Mnemonics for different operators: ID-S2A2MPLE
The introduction of the ID-S₂A₂MPLE Mnemonic for the handover checkpoint of the ambulance
service, did not show any effect on the satisfaction ratings with the handover process. On the
contrary, there was rather a trend towards less satisfaction post-intervention. This is a puzzling
result we did not expect, especially concerning communication and collegial atmosphere. Here
the satisfaction reduced significantly. This might be because of the different backgrounds and
working places (Meisel et al. 2015). Ambulance staff and hospital staff have a different
education and working field, as well as different workflows. How to deal with communication
problems with people who come from a different provider and have different fields of operation
was not part of the training the ED-staff received. However, it is a very crucial point of
communication failure and should be addressed for both sides. Here, it would be especially
important to have regular communication trainings for both, ambulance and ED-staff. Training
only one side, would not be sufficient to enable a firm understanding and efficient
communication on both sides. The survey only included questioning the EMS, but since the
staff come from different providers and do not belong to the university hospital, no training for
these was done. Only a short introduction of the new ID-S₂A₂MPLE Mnemonic was sent to the
different ambulance providers. The respective provider was asked to inform its employees, but
this off course could not be secured from our side. On the other hand, the ED-staff did receive
communication and stress coping training. This was done during the implementation process
of the ID-PHONE, where a definite trend towards more satisfaction of the patients can be made
out. The results underline the already existing studies that new mnemonics and
45
handovers only contribute to a better handover, if they are accompanied by training
(Owen et al. 2009; Manias et al. 2016). This might explain, why satisfaction ratings show no
rise, but rather a fall or stagnation by the ambulance staff.
We do not know what schooling the ambulance staff receive and can therefore interpret their
returned survey sheets only as to whether the communication training accompanying the ID-
PHONE implementation also enhanced communication between the different professions and,
as to whether the new mnemonic bettered the handover.
What can be said, is that EMS staff perceived structure in handovers to be more important
after the implementation of the new handover. They were not more satisfied with it but
recognized that it was important to have a structure, set responsibilities and specifications of
this process. Off course, the EMS already have a protocol, by which they operate. This is also
used for handover. Since it is quite detailed, the idea was to simplify this protocol and create a
shared mnemonic, by which ED and ambulance staff go. This should lead to creating a
common ground of understanding and demands. What we observed was the ID-S₂A₂MPLE
Mnemonic not actually being used as such for the handover though. The reality showed that
for ED-staff, the ID-S₂A₂MPLE mnemonic was used as a guideline and ground of shared
understanding. The ID-PHONE was used by the ED-staff for noting down the handover
information. The EMS staff have their own protocol given by their operator. They leave this
protocol with the data of the patient, at the hospital. This is the reason, they rather go by their
protocol than by the new mnemonic. Nevertheless, a poster with the ID-S₂A₂MPLE Mnemonic
is displayed at the area of handover, for staff to orientate themselves. In practice, ED-staff use
the ID-PHONE Mnemonic to note down the patient’s data and EMS-staff orientate themselves
with the help of ID-S₂A₂MPLE. Whenever there is confusion in structure or questions about
missing information, the ID-S₂A₂MPLE poster can be used for a common operating ground.
We did not set a timer, to allocate the waiting and handover time of the EMS staff but asked
for an estimate by the latter. The EMS staff estimated both time periods to have risen after the
intervention, by 30 seconds to one minute. Interestingly they estimated the total amount of time
spent in the ED the same in both time slots, at 15 minutes. These numbers cannot be used
statistically in the analysis, since they cannot be objectified. It is nevertheless interesting, to
see that there is a feeling of more time needed for handing over the patient. This reflects the
controversy in the literature. If a more structured handover is introduced, it should, in theory,
reduce handover time. In practice, most studies have shown that it increases handover time,
because of it being more detailed (Keebler et al. 2016, p. 1196), (Lendemans 2012, p. 301).
Our results show a similar trend. To make assumptions or statements about these time issues,
an objective time measurement would be necessary.
46
Furthermore, we only questioned ED-staff about their satisfaction with the handover and
included information before the new mnemonic was introduced. It would have been interesting
to see, whether ED-staff satisfaction changed or also stayed the same. Also, how often they
used the protocol of the ambulance after the intervention.
Before the intervention only half of the time, the protocol of the EMS was used after handover,
for further treatment. The question, which poses itself here is, why this is not done more often,
and whether this could bring a stronger improvement, than changing the already trained
handover structure of the EMS. Since the services do not only deliver to one hospital, but many
different ones, it should pose quite a challenge to adapt to different handover structures at
each hospital. It would make more sense, to train the ambulance staff regularly on how to
structure a handover properly and what data is of importance for the further treatment. At the
same time, hospital staff should be trained on communicating with staff from other
backgrounds and to structure their own uptake of information and questions. Simulation
trainings and feedback thereafter on a regular basis, would be of need. Since this can only be
done in a joint effort, with enough finances, the importance of this needs to be recognized by
all operators involved, and regular training be set as a top priority for patient safety. The results
show that only implementing a new structure, does not bring about the desired effect.
4.2. Training and new handover: ID-PHONE
This can be underpinned by the second section of the survey, namely the implementation of
the ID-PHONE Mnemonic, for handovers within the department and the concomitant training.
Here, the new handover scheme was communicated to all people involved, it was
accompanied by a training of the multipliers thereof, and specified on sheets, used in the
treatment of patients. It was also adjusted to the needs of the specific department after a trial
period. All leading physicians agreed to the new structure and made sure, it was applied during
handover and ward rounds. This may be the reason, why unlike the EMS staff, patients as well
as ED-staff to a certain extent were more satisfied with the handling of the patients’ treatment
in the second survey round. Another important finding was that patients were already very
satisfied with the work of the ED before the intervention. The staff on the other hand did
not believe their work to be satisfying for the patient. They were not able to estimate their
patients’ satisfaction with their treatment, or what was important for them, correctly. As shown
in the results, they do not know, what is really important for the patient. Information about
medication is rated as least important for patients, which is a complete misjudgement. This
information is indeed important for patients and rated as one of the things, they were least
satisfied with. Apparently, staff believe patients to have other worries, during their stay,
supposedly more pressing. The results show though that patients would like to generally be
47
better informed. This probably gives them a feeling of having somewhat control, in a situation
where they actually are out of control for the most part. This can also be seen in the low
satisfaction ratings on information about waiting time and information about the time duration
of their stay in the ED. It is noticeable that patients were least satisfied with the information
they got. The actual treatment they received was, for the most part, very satisfying in their
opinion. Communicating with the patient, letting them know, what is happening and when, is a
crucial point, which should be set high on the importance scale of the ED.
The least satisfied are those, who have been in the ED for 4-6 hours. Often, these are the
patients, which have passed the acute phase of their diagnostic and treatment successfully
and would now like to leave the ward, or at least receive some more information, e.g. about
the next steps. The problem of relocating patients to other wards within the hospital, is already
being tackled by the department. It put a substantial amount of extra stress on the staff, having
to organize beds for the admitted patients, since more than often, no other ward had enough
beds, to take up new patients. For this purpose, the department engaged an extra workforce,
who is exclusively responsible for the discharge and relocation of outgoing patients. Verbal
feedback allowed to draw the conclusion that this already reduces the stress of the staff
substantially and allows a better workflow.
The problem of keeping patients in the ED too long, is a worldwide phenomenon. In the UK, it
was tried to tackle this, by setting a rule, by which every patient arriving at an emergency ward
must be treated and discharged within 4 hours (Jones and Schimanski 2010). This is quite a
high set goal and can cause more stress, than lower it. Which is the reason, the target was set
for only 95% of the emergency cases in the meantime, and a discussion about the benefit for
patient security is still ongoing (Hughes 2010), (Campbell) But it shows the importance for fast
treatment and discharge, also having in mind the patient’s safety and satisfaction.
A very rewarding result is the great satisfaction with the professional competence of the
doctor, on both sides. Apparently, the patients as well as the staff believe their work to be
professional and satisfying. In the second survey round, no statistically significant difference
existed between the satisfaction ratings of staff and patients on this topic. What could have
been a trigger for this boost in satisfaction, making it the item the staff was most satisfied with,
is the presentation of the results of the first round of the survey. A poster was displayed in the
ED, showing that patients were already very satisfied with the work of the ED and that the staff
falsely estimated them not to be. This might have given them more confidence in their work.
Noticeable here, is the comparable low satisfaction with themselves on the non-professional,
interpersonal level. It seems that they are not confident with themselves on the non-technical,
communication-level but much more confident on the technical, medical knowledge-based
level. This is no great surprise, since knowledge of medical facts and interventions, is the basis
48
of today’s education. Non-technical skills, that is cognitive and social skills, on the other hand
are neglected in the medical education and training, especially in the German setting, but there
is also literature on this neglect being apparent in North America (Manser et al. 2010; Gordon
et al. 2017; Gordon et al. 2012, p. 1043; Raduma-Tomàs et al. 2011). Here, not only
appropriate communication, but also stress reduction techniques play a major role (Ríos-
Risquez and García-Izquierdo 2016; Ratanawongsa et al. 2012). This is a field, where regular
training and more focus, already in the basic medical education, is necessary.
The study showed that already one training session for communication and stress
management has a positive impact. Ward rounds and handovers are better structured, the
nursing staff has a better-defined role, more people use written, structured protocols and the
patients feel to have more possibility to talk about their experience of illness. Also, the staff
indicates that there was an advancement in their own techniques to deal with stress and to
communicate effectively. This could be a result of the training and thereafter better structure
of the processes in the ED. Here more surveys would need to be done, before and after
training, and more staff should take part in this. Furthermore, the training itself should be
analysed and best practices drawn from it. Through this, recommendations for further trainings
can be compiled and the direct impact of the training, independently from other restructuring
processes, analysed.
4.3. Downfalls and recommendations for further research
The aim of this study was to examine what impact a better structure in handovers and training
in non-technical skills have on the satisfaction of patients and staff. Satisfaction is off course a
very important parameter, for measuring the success of this intervention. In theory though,
such an intervention should primarily have a positive influence on patient safety. We were not
able to gather information about this aspect, although it was the overall goal we wanted to
achieve with this intervention. A further theory, of other studies is that less stress of the staff
also leads to better treatment and therefore less adverse events. Since a great amount of data
would have been necessary, to allocate data about the outcome of the patient’s treatment and
the reason for this, we were not able to include this aspect into our survey. This leaves us not
being able to verify the theory that better structured handovers and NTS training lead to less
adverse events and therefore greater patient safety. Additionally, the subjectivity of the
answers and specific setting of the surveyed ED, hinders the study to be objectively
comparable. Therefore, we can make conclusions and recommendations for the Freiburger
University setting of the emergency department, but not compare it to other settings or surveys.
Another pitfall of this study is the size of the questioned collective. We had quite some
difficulty, acquiring enough emergency personnel, in order to make statements about the
49
statistical significance of the results. This was due to different reasons: on the one hand,
there is only a limited number of employees, which could be questioned. On the other hand,
the high working load as well as stressful and time critical treatment of the patients, leaves
staff with only little spare time on their hands. The main reasons for not filling out the
questionnaire, were not having enough time for doing so, staff forgetting about filling them
out, or that they were annoyed by this task and refused to fill out the sheets. Here, less
question items would have probably raised the compliance. We face similar difficulties with
the EMS, although they had somewhat more time to fill out the sheets. Here, we took out
several question items after a trial run, which were not of such great importance for the
analysis of the intervention. This elevated the compliance.
For future research, a bigger case number would be of great importance. This would allow for
more statements on the findings, which can be statistically underpinned. Since this is a case
study on the specific setting of the University Hospital of Freiburg, a generalization cannot be
done. The structure and training were adapted to the demands of the department and can
therefore not generally be used in other emergency department settings. But
recommendations for other houses can be posed, with the annotation, to adapt this to their
respective setting and evaluate its success and applied changes. In order to really implement
a certain handover scheme in the minds of the different ambulance operator staff, it would be
sensible, to implement the same handover scheme in all hospitals, these operators deliver
patients to. In our case, these would be the hospitals of Freiburg and its surroundings. This,
on the other hand, probably cannot be done, without a strong combined effort of all of these
hospitals. For now, only recommendations, collected through this study, can be transferred to
other institutions, with the call for more similar studies on this topic. Another limiting factor of
this study is the fluctuation of the ED-staff. To control for rating fluctuations because of personal
reasons, it would make sense to question the same person before and after the intervention.
Especially when having such a small case number, as found for the ED-staff. This was not
possible, due to a part of the physicians only rotating into the ED for a limited amount of time.
To make statements on the influence this kind of intervention has on patient safety, other data
needs to be collected. The study would need to be conceptualized on a larger scale, collecting
patient data on their treatment and outcome. Here, a detailed analysis of the reasons for
adverse events would need to be made before and after the intervention. In addition to that, it
would be of great interest to analyse the influence NTS training has on staff stress levels and
patient safety. It would make sense to do this training concomitantly, but this makes it hard to
distinguish the respective influence. Separate training sessions, independently from
restructuring processes, could help filter out the lone effect NTS training has. In general, more
50
studies on these kinds of interventions in Germany would be necessary, in order to compare
findings and formulate best practices.
What has not been discussed in this paper at all but is of great importance for the treatment of
patients in the future, is the growing digitalization. In the Freiburger UNZ the patient sheet, filed
out by ambulance staff, is in the process of being digitalized. This means that all information
will be available in the digital form and therefore easier to access. The digitalization has in
general far reaching consequences for treatment and information collection and transfer. This
is quite a big topic, which opens a whole new field of discussion and would need separate
studies. It is however, an important topic for handover structures and will have a crucial
influence on handover practices.
51
5. Conclusion
This survey was conducted to examine the influence standardization of handover structure has
on the satisfaction of patients and staff in an emergency department (ED), as well as in the
emergency medical service (EMS). New handover mnemonics were introduced.
Concomitantly surveys depicting what is of importance for patients and staff and how satisfied
they are with the current workflow, were carried out. The new handovers implemented were
the ID-PHONE mnemonic for handovers between shifts in the emergency department, and the
ID-S2A2MPLE mnemonic for handovers between EMS and ED. Furthermore, the benefits
additional training on communication, stress management and structuring information has on
satisfaction, was considered. The overall question in mind was, whether standardizations of
handovers bring about an actual benefit to the workflow, as well as care and treatment of the
patients. The study was conducted as a case study in the emergency department of the
University hospital of Freiburg, Germany.
Our findings show that first and foremost, patients were already very satisfied with the work of
the physicians and nurses of the emergency department. The staff on the other hand estimated
their work less satisfying. Especially on items concerning non-technical skills, like
communication, information-transfer, stress-management and the like, they were significantly
less satisfied with their work, than the patients were, except for their professional performance.
Items, the patients rated least satisfying all concerned aspects of information transfer.
Information about medication, waiting time and the time of their stay in the ED were the three
items they were least satisfied with. Although satisfaction ratings of patients were already quite
high, an overall trend towards more satisfaction in the second survey round was observed.
The same can be said for the ED-staff satisfaction ratings. The ambulance staff on the other
hand, showed no change in their satisfaction. Although a statistically significant rise of the
importance rating of standardized protocols and handover time was observed. Whether or not,
this intervention has an influence on the quality of care and treatment and can raise patient
safety, has yet to be shown.
The two different trends in satisfaction ratings between EMS and ED staff, underpin the theory
that new handover protocols are most beneficial, if accompanied by a communication training.
This training was conducted during the survey period, but only for ED-staff. The results also
lead to the conclusion that non-technical skills are an important but often neglected factor,
contributing to the quality of care. More training in this field could reduce stress and raise the
satisfaction of the staff. This was not verified statistically, since there was no direct comparable
control group with a similar setting and working background, which did not receive any training.
Studies conducted on this topic in the US, support this assumption though (Dawson et al. 2013;
Owen et al. 2009).
52
This survey feeds into the literature on the importance of standardized handovers. This field of
research has grown significantly in the anglophone countries, but not yet established itself in
German emergency medicine research. Since this is only a case study, it is of great
importance, to have further case studies of this kind for comparison in the German emergency
care setting. Additionally, a study analysing the influence these interventions have on patient
safety would bring about a great contribution to the literature. This study can be used as a
basis and support for further research on handovers in the German emergency medicine
sector.
53
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VII. Appendix
Figure 9: Ambulance service questionnaire
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Figure 10: Patient questionnaire
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Figure 11: German version of the ED-staff questionnaire concerning stress management techniques and patient treatment
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Table 7: English translation of the ED-staff questionnaire concerning stress management techniques and patient treatment
1. Communication and stress
1.1. I know and use communicative techniques, which help to communicate effectively with the patient
1.2. I know and use communicative techniques, which help to communicate effectively with my team and supervisor
1.3. I know and use deliberatively techniques, which help me to cope with stress
1.4. The communication with colleagues is a substantial factor of stress for me
1.5. The communication with patients and/or their relatives is a substantial factor of stress for me
1.6. The communication with fellow residents/ superiors is a substantial factor of stress for me
2. Ward rounds
2.1. The procedure and involvement of patients during the ward rounds is strongly dependent on the attending round-leading physician
2.2. Ward rounds are clearly structured. This structure is known to all people involved and everyone has a defined responsibility
2.3. During ward rounds, the patient is the centre of attention and her or his well-being is elevated through physician-patient communication
2.4. The nursing staff have a set, clearly defined role at every ward round and bring in important information about the patient
2.5. The patient is given the opportunity to report about her or his personal experience of the illness
3. Patient handover
3.1. The handover follows a known, written documented procedure
3.2. During the handover of patients, the transfer of information is strongly dependent on the physician/nurse handing over
4. Discharge of patients
4.1. The discharge of patients follows a known, written documentation
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4.2. I know, which information patients need for a successful discharge to their home and make sure that these are transferred
5. General
5.1. Our organisation and communication are directed towards the support of patient satisfaction and their well-being
5.2. My work is directed towards satisfying the patient in the best possible way
5.3. My work is directed towards satisfying my colleagues in the best possible way
5.4. My work is directed towards satisfying my superior in the best possible way
5.5. My work is directed towards satisfying myself in the best possible way
6. Specification of team data: profession, time span already employed, like/dislike working in the UNZ
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Figure 12: Questionnaire for ED-team concerning handover from emergency medical service to ED
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Figure 13: Freiburger ID-S2A2MPLE scheme
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Figure 14: Freiburger ID-PHONE scheme
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Figure 15: Freiburger ID-PHONE-handover scheme, with the specific tasks each position needs to fulfill
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VIII. Conflict of interest
The authors of this paper certify that they have no affiliations with or involvement in any
organization or entity with any financial interest (such as honoraria; educational grants;
participation in speakers’ bureaus; membership, employment, consultancies, stock ownership,
or other equity interest; and expert testimony or patent-licensing arrangements), or non-
financial interest (such as personal or professional relationships, affiliations, knowledge or
beliefs) in the subject matter or materials discussed in this manuscript.
We worked together with Harald Seidler from Flow Promotions©, in the creation of the staff
training. Here, no money was paid, nor did he take part in creating the study. No rights to the
content or results of this study are held by him or Flow Promotions©.
Ethical Approval was given by the ethical commission of the University of Freiburg. The votum
number given is: 211/16.
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IX. Acknowledgements
My first and foremost gratitude goes to Dr. Felix Hans, who has been a great mentor, always
ready to give advice and on top of that helping and patient with me throughout the process of
creating this dissertation.
Then I would also like to thank Harald Seidler for the help in creating a staff training and off
course Prof. Dr. Hans-Jörg Busch, who made this whole project possible.
I would also like to thank Joß Bracker, Dr. Nadine Schimpf, Alex Impola and Matthias Drews
for their help in design, statistics and proof reading. You saved me a lot of nerves.
And last but not least, I would like to thank my parents, for giving me the opportunity to study
medicine in the first place. Thank you, for always believing in me.
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