Good Example Of Dissertation On Clinical Handoff Communication Of Ambulance Patients In The Emergency Department

Published: 2021-06-18 06:48:16
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Transfer of professional responsibility and accountability for some or all aspects of care for a patient, or groups of patients, to another person or professional groups on a temporary or permanent basis is referred to as clinical handoff. Transfer of patients and their information has an element of risk. This process can involve a written report, however the process mostly involves verbal information exchange between allied health staff, nurses, and physicians. There are minimal guidelines for information exchange, and nurses can take a major role and participate in interprofessional collaboration to improve the practice.
Substandard handoffs potentially can place patients at risk for inaccuracies; miscommunication plays a major role in adverse events. Institute of Medicine (1999) reports at least 44,000 people die each year from preventable medical errors; and Joint Commission (2013) estimates 80 percent of serious medical errors involve miscommunication between caregiver when patients are transferred or handed off. Clinical handoff is a high risk area for patient safety and failures have been identified as major preventable cause of patient harm.
In a busy emergency department (ED), a substantial number of patients are transported to the ED via ambulance. Most times patients are unable to communicate any information, and rely on health professionals to transfer accurate information for appropriate care. In the ED, the goal of optimal information exchange is seen as a challenge, due to high levels of stress and high patient turnover; however quality information exchange between healthcare professionals is necessary to maintain patient safety. Information received from EMS, impacts safety for all patients arriving via ambulance, including nursing planning, implementing, and clinical decision making. These are based on the information received. At the present clinical state there is no standardize methods of transferring information. Standardization of clinical handoffs provide the benefits of improved patient outcomes and safety, timely and high quality care, and paramedic and ED staff collaboration. Yong (2008) the use of emergency teams to receive paramedic handover might improve safety and efficiency by reducing risks of miscommunication and/or unanswered questions between them and those making downstream referral and admission decisions. The IMIST-AMBO protocol give the clinical staff the opportunity to regulate clinical handoffs and provide a structured clinical information exchange of ambulance patients in the ED. IMIST-AMBO stands for Identification of the patient, Mechanism/medical complaint, Injuries, information relative to the complaint, Signs/vitals/GCS, Treatment and trends/response to treatment, Allergies, Medication’s Background history, and Other (social) information (Iedema, Ball, Daly, & Young, 2012).
The purpose of the project is to study the handoff communication in its current state based on the IMIST-AMBO protocol. The aim of the project is to identify the inefficiency of the procedures and discuss approaches to improve communication. The project proposes if the handoff communication process improves, there will be a reduction of potential adverse outcomes and improve patient safety, and clinical outcomes. “An accurate and effective handover communication is central to ensuring continuity of care, and to preventing inappropriate modification or omission of any component relating to critical treatment” (Iedema et al., 2012, p. 627). PICO Question: Among the ED adult patients arriving with EMS, can the analysis of the current hand off reporting methods and documentation ascertain problems with the current process that would impact patient safety?
Literature Review
The literature search relating to patient handoff communication proved to be challenging. This subject matter has few articles available. The nature of caring in the ED is under-researched and the patient’s arrival by ambulance to the ED and nursing handover (Bruce & Suserud, 2005, p. 201).
In the search for studies, it was noticed most of the articles came from outside the United States, mainly Australia. The publication of the articles were fairly recent, within the last ten years with the latest being in 2013. The purpose for the majority of the studies related to communication between pre-hospital staff/EMS and the receiving/triage nurse. Evans (2010) study attempted to evaluate how much information was loss during transfers from the scene of the incident to the hospital. Also, Owen (2009) research investigated the perceptions of paramedics, and hospital receiving staff (nurses and physicians) about what enables, and constrains the handover in the ED. Although, most of the articles focused on the handover process, a study was found to be relevant to the review. Farnan (2009) studied medical student’s knowledge with Observed Simulated Hand-off Experience (OSHE) and their sign-out skills utilizing an assessment tool. Collectively the main purpose of the articles was examining the handoff process between health professionals
The research designs for the majority of the studies were observational, with three literature review, and one random control study. Ye (2007) utilized an observational design to evaluate the handover methods in three large metropolitan EDs and the ED physicians were surveyed to capture the perceived quality of the communication. Dawson (2013) performed a literature review of quantitative and qualitative studies in which the common themes were “barriers to communication, “multiple or repeated handover”, need for a “structured handover tool”, and other “communication methods and education/training to improve handovers were reviewed. Evans (2010) randomly selected 25 trauma patients to obtain handover information via audio/ videotaped and compared it to the written documentation to determine information loss.
The subjects and sample size varied from each research. Ye (2007) had the largest sample size of 914 patients; handoff communication observed in a 3 month period. Bruce (2005) conducted a qualitative descriptive interview with the smallest sample size of six. The criteria for selecting the subjects were at least three years’ experience in the specialist and currently working in the ED. They were chosen by their superiors. In this particular study the participants were asked to describe the handover experience from the first contact with the ambulance personnel. The average sample size was an observational study by Evans (2010), with twenty-five. These cases were randomly selected from a database. The criteria were based on patients involved in a trauma such as pedestrian struck by motor vehicle accident, burns, or traumatic amputation.
The majority of the studies were observational or literature reviews with no listed interventions. However, Idema (2012) investigation utilized a video-reflective ethnography for the paramedics to analyze the use of the IMIST-AMBO handovers. Post-training was provided to EMS. The ED staff, noted a greater volume of information and consistency. In this study the ED clinicians suggested and an improvement in comprehension and retention due to fewer questions from ED staff, a reduction in handover duration, and fewer repetitions by both EMS and ED staff. Evans (2010) study had a similar intervention in which the identified trauma subjects were video/audio taped and information gained was compared to written documentation. The intervention from these studies were appropriate to demonstrate information transfer inconsistencies.
Evans (2010) research was the only article that elaborated on the data analysis process. The author utilized the Pearson’s Chi squared analysis to compare data items handed over in the pre-hospital and in-hospital setting. The study demonstrated seventy-five percent of all data items verbally handed over by paramedics were recorded on the trauma notification sheet in the ED and Trauma Center. And in the hospital setting the most comprehensive verbal handover occurred when paramedics provided a face to face report to the team in the ED. Also it was noted nine percent of the data items were not documented at all, for example allergy status and site of injury, which increases the patients risk for harm. Ye (2007) observational study analyzed data by averaging the figures collected from the questionnaire. The analysis showed a large majority of handovers was adequate and the median quality of handover score was a 3 (range 1-5). No correlation was found between the number of items handed over and the quality of handover score.
The consolidation of the study findings demonstrate there is loss of information, which has the potential of adversely affecting patients Owen (2009) found there was a fragmentation in communication The major limitation of the studies demonstrated a questionable generalization of the results to other ED settings. Iedema (2012) admits study limitations include a short amount of time given to train EMS on the IMIST-AMBO protocol, which may have an effect on the results. Another limitation in observational studies are the various styles of handoffs may create bias. Jensen (2013) suggested experimental studies in this area are very sparse, and recommendation in papers are often based on opinion, interviews, and quasi-experimental results. However with the current findings there are implications for practice. A common theme in all the studies suggested a standardization of the handoff process, to reduce missing and disorganization of information. Improving the protocol for this practice has the potential to improve patient safety and a smoother transition of care.
The assignment of levels of evidence according to AGREE: Appraisal of Guidelines for Research and Evaluation, ranged from 1c to 3b. Evans, Murray, & Patrick (2010) was assigned the highest level, 1c according to the AGREE criteria. This random control study evaluated information loss and discordance as patients were transferred from the scene of an incident to the trauma center. Four out of the ten studies was assigned was a 3b, which were individual case control studies. Overall the studies the studies maintained a GRADE “B” or better with the exception of one study that meet the criteria of a “C”.
The review of literature suggests there are identified gaps in the current studies, which suggest further investigation is needed. It also suggest the handoff communication from EMS to receiving ED staff evaluated. The work flow process need to be reviewed and analyzed in depth to obtain a clear picture of the current state.
The anticipated study will be conducted in the emergency department of teaching public hospital. Elmhurst Hospital, part of the Health and Hospital Corporation (HHC) is categorized as a Level I trauma emergency department, and often very busy with 80 to 100 patients in the adult section of the department at any given time. Approximately, a third of these patients arrives via ambulance. The adult ED consists of an ambulance receiving triage area, two medical treatment areas, fast track area, a ten bed observation unit, four bed critical care room and three bed trauma room.
Recruitment of participants
Fire Department of New York (FDNY) emergency medical services (EMS) brings the majority of the ambulance patients and will be recruited to participate in the project. EMS along with triage nurses will be enrolled and educated on the IMIST-AMBO protocol. In enrolling the EMS, the research team will send a formal application to the FDNY requesting that their EMS staff members be recruited to take part in the study. In the application, the FDNY management will be requested to assign the recruited participants to Elmhurst Hospital Emergency Department. In this case, the EMS team bringing ambulance patients to Elmhurst Hospital Emergency Department will comprise of members who have been enrolled in the study. Upon receiving a formal consent from FDNY, the research team will proceed to recruit the prospective EMS members on the basis of the set inclusion and exclusion criteria. In terms of the inclusion criteria, the prospective participants will be recruited from the EMS members whose workdays will cover the entire period of the study. This criterion will be used because the study reacquires that the participants should be available during the entire period of the study. Therefore, the EMS members whose workdays will end before the end of the study period will not be enrolled in the study. Similarly, EMS who will be on leave at the time of recruitment will not qualify to be enrolled in the study. The prospective participants will also be recruited from the EMS staff that will not have been booked to undertake an assignment that will last for the entire duration of the study or hinder their participation in the study. Therefore, the EMS staff whose workdays will fall in the duration of the study but will be in a prior arrangement to take up a different assignment throughout the period of the study will not be eligible to take part in this study.
The recruitment of the triage nurses will also be based on the set inclusion and exclusion criteria. In this case, the prospective participants will be triage nurse working in the Emergency Department at Elmhurst Hospital. The study participants will also be picked from the triage nurses whose workdays will cover the one month period of the study. Furthermore, the nurses will be picked from those who will not be in prior arrangement to undertake a different assignment that might hinder their participation in the study. On the other hand, nurses whose leaves will begin in the course of the study period will not be eligible to take part in the study. In addition, nurses who will be on leave at the time of the recruitment exercise will not be included in the study. The triage nurses who will have been booked on a different assignment that will hinder their participation in the study will also not be enrolled in the study.
Recruitment will take place one month before the beginning of the survey. The recruitment exercise will be conducted at the main FDNY headquarter in New York and Elmhurst Hospital Emergency Department. The research team will send a formal request to the authorities of both organizations for an opportunity to conduct the recruitment exercise. The date will be set by the authorities of both the organizations. The recruitment will be conducted during the day and at night. Two teams of 3 people will be appointed with each team being assigned either of the shifts: night or day shift. During both shifts, the recruiting teams will report to the respective premises earlier than the normal reporting time of the prospective participants. Systematic sampling will be used at the main FDNY headquarter in New York and Elmhurst Hospital Emergency Department to recruit the study participants. In this case, the prospective participants will be recruited in order of their reporting times to the work stations. Those who will report first will be picked while those who will report next will be skipped. The third to report will be picked and so on. Then, members of the recruiting team will ask the prospective participants if they would be willing to take part in the study. The prospective participants will then be given consent forms to sign in order to make formal declarations of their willingness to take part in the study. In this first phase of the recruitment, the study targets 30 participants from each of the two organizations. Next, the recruited prospective participants will be assessed to determine if they meet all the inclusion criteria set. Those who will not meet the criteria will be dropped while those who will be found to have met the criteria will be enrolled formally to the study. The participants will be informed of the start date prior to the conducted survey. The nurses will also be made aware.
Prior to the actual date of the commencement of the study, pre-study will be conducted at the emergency department of Elmhurst Hospital. All the participants will be expected to take part in the pre-study. The pre-study will be conducted immediately after the completion of the training of the participants. During the pre-study, all the concerns of the participants will be addressed. Besides, possible challenges will be discussed and suggestions for their possible solutions will be made.
Data collection procedure
The project will involve collection of data from a convenience sample, obtained from patients arriving in the ED via ambulance. The survey will take place across all shifts and all days from patients arriving via ambulance; the collection of information will be randomized to gain enough sampling to allow for analysis. Observing the handoff process will take approximately one month. Prior notification of patient’s arrival will be excluded from the study. The researchers will be present at the triage area during data collection where they will observe the entire process of the transfer of information between regarding patients between the EMS and the triage nurses. The researchers will be equipped with IPad and notebooks which they will use to record the data identified by the IMIST –AMBO protocol and documentation and given to the triage nurses. The data exchange will take place as follows: the EMS will arrive with the ambulance patents. The patients will then be taken to the respective beds ready to be put on care. In the process, the EMS will give the researchers a copy of the handoff information designed according to the IMIST –AMBO protocol. The EMS will also give the triage nurses a similar document. The researchers will then review and evaluate the data. Patient charts will then be subjected to an audit after the handoff report, to evaluate if the information was accurately documented in the electronic record.
Data analysis
The data will be analyzed using a correlational statistical analysis to examine relationship from the data identified by the IMIST –AMBO protocol and documentation. The study will analyzed percentage distribution to organize the data according to the protocol, then divided and compared according to categories of information transferred through utilization of the protocol and frequency of occurrence. The post chart audit will be recorded and analyzed for percentage distribution and confirm if the data was documented in the patient electronic health record.
Protection of Human Subjects
Prior to the study, an in-service will be provided reinforcing the importance of accurate and complete handoff reports, which ensures patient safety and positive outcomes. The healthcare providers, will be inform of the study goals, to capture the handoff process in its current state. Verbal consent to observe and evaluate the handoff process will be obtained. EMS and triage nurses will be informed their participation are voluntary and their identity would remain anonymous and their participation would not affect their employment; and can withdraw from the study or decline to participate at any time. There will be no identifiers of patients, EMS, or nursing staff collected. There will be no coercion or deception in attempt to have staff participate in the study.
The study is structured, to exclude human subjects and focus on the handoff process in its current state. The emphasis of the project will be information exchange and how it is communicated.
Two Institution Review Board (IRB) applications was submitted, Chamberlain College of Nursing (CCN) and Mt. Sinai/HHC Elmhurst Hospital. The study received and exempt IRB approval from the CCN. At this time, Mt. Sinai IRB procedures have proven to be a lengthy process and the organization’s determination is currently pending.
The major stakeholders of this project are the directors of nursing, medicine, and emergency medical services. Upon sharing the details of the study, the project received full support and seen as a quality improvement project. It has been acknowledge, the importance of handoff reports and the role it plays in the support of patients receiving appropriate timely care. Health care organizations reported an increase in patient and family satisfaction; staff satisfaction; and successful transfers of patients one health care organization reduced readmissions by 50 percent; another healthcare organization reduced the time it takes to move a patient from the emergency department to an inpatient unit by 33 percent ("Joint Commission Center for Transforming Healthcare," 2013). The interprofessional collaborative project gives the organization an opportunity improve the current state.
The major barrier to this study is obtaining organization’s IRB process. It remains to be a stringent and lengthy process, in which the original exempt application was submitted and denied. The second application has been resubmitted and is currently pending. While waiting the approval, I continue to keep the stakeholders updated and plan to obtain the data and complete the study.
Apart from the slow process of the approval of the study by the organization’s IRB, the study is likely to face several other challenges. First, data collection will possibly be difficult during major crises. The study recognizes that during the study period, major crises involving many casualties might occur. Such events might lead to overcrowding of the facility. Under such circumstances, exchange of the information might be difficult. Indeed, the triage nurses, EMS, and the researchers are all likely to experience difficulty in the exchange process of the information. In such cases, information exchange is likely to be hampered. However, the researchers intend to address the challenge by ensuring that all the protocols of handoff communication are adhered to under the situation. Out of the researchers present at the triage during the transfer of the information between EMS and the triage nurses, two will be selected to monitor the process while others take down the notes of the data obtained. Another possible challenge that the researchers are likely to encounter during data collection exercise is the possibility that the EMS might not be willing to give certain information regarding the patients to the researchers. This might be due to the nature of the patient’s injury or unwillingness by the patient’s next of kin to have the information shared with the third party.
The presence of the researchers at the emergency department is also likely to disrupt the normal functioning of the facility. The fact that EMS will also give the handoff data to the researchers is likely to slow down the workflow in the emergency department since the staff at the department will have to take some times before adjusting with the changes that will have been created owing to the entrance of the researchers into the system. However, this potential challenge will be addressed by conducting a pre-study with an aim of familiarizing the participants with process. In addition, pretest will provide an opportunity for all the participants to seek for clarification of how emerging issues might be dealt with. In addition, each participant’s concern will be addressed during the pre-test. The pretest will be conducted at the emergency department in such a manner that it will simulate the actual situation under which the study will be conducted. Pretest will also provide an opportunity for the participants’ weakness and strengths to be identified. The participants ‘weaknesses will be addressed. The team will then be organized in a manner that facilitates efficient data collection as well as operations at the department. In cases where the patient’s next of keen or the patients themselves will not be willing to have information regarding them shared with the third party, the survey team will respect the patients’ decision. The study is intended to observe all the ethical concerns that might arise during the inception, implementation, and evaluation of the study. Indeed, consent will be sought appropriately at the right stage of every process involved in the study.
Another possible challenge likely to face the researchers during the study might be lack of support from the emergency department or the entire facility. The survey team will need every single support from the hospital in all the aspects of the study. As a matter of fact, the study recognizes that working in isolation is impossible especially owing to the fact that the study intends to use the facility’s resources to meet its goals. In addition, the study recognizes that collaboration among the hospital staff, the EMS, and the researchers is needed to help the hospital achieve its short-term goals and long-term goals. In addition, the corporation is indispensable to enable the project proceed to its conclusion and achieve its goals. However, it is recognized that while there might be high level of cooperation at the beginning of the study, the hospital staff might lose interest in the study before it ends. Under such circumstances, the researchers are likely to have a hard time realizing the successful conciliation of the study. In order to address this challenge effectively, adequate effort will be made to ensure that the study does not interfere with the normal operations of the emergency department as much as possible. One possible approach through which inference with the normal operations of the emergency department will be reduced is scheduling the study activities to comply with the operations of the hospital’s emergency department. Consequently, the study will be structured in such a way that in fits into the hospital schedule and not the other way round. In this case, all the activities involved in the study will be scheduled to take place at the appropriate time in which no interference with the department’s operations will be noted.
Another approach that will help boost and maintain cooperation from the staff working at the emergency department involves taking part in the facility’s regular training activities in which the study researchers would explain the importance using the IMIST-AMBO protocol to guide handoff communication between the various healthcare personnel in the facility. This approach is likely to help raise a sense of the importance of the study in the healthcare practices among the key decision makers in the hospital. Besides, it is likely to earn the study more support since the decision makers of the facility are likely to gain more interest in the result of the study. Consequently, they are likely to step up support in order to ensure that the study is carried out in a manner that is likely to protect its validity and reliability.
Another possible challenge might arise as a result of situations that would seem to require the study observers to engage in activities that are appropriate but not related to the study objectives or part of their responsibility as delegated. For instance, in cases of emergency, the observers might offer certain assistance that involves activities not related to the study objectives. In such cases, the observers might also face ethical dilemma. The study seeks to address this challenge by informing all the observers taking part in the study to familiarize themselves with the protocol guiding all the operations at the emergency department. Besides, the observers will be trained to familiarize themselves to adhere to the standards of operation, and any other rule guiding all the operations in the facility. This approach will help ensure that the study observes are able to make appropriate decisions on the best course of action under all circumstances while carrying out the study. The observers will also be reminded that proper channel of communication should be followed while carrying out the study. This approach will help ensure that the observers are able to address issues that might emerge in the course of the study. The challenges that are likely to emerge in the course of the study have been anticipate and possible ways of addressing them have also been proposed. However, not all challenges can be anticipated.
Having taken care of the possible challenges, the implementation of the study will commence two weeks after the training of all the study participants. All the resources needed will be availed in a timely manner throughout the study period. Stationeries will be provided to the observers who will collect data from the emergency departments. Meals for the observers will also be catered for. In this case, the observers will take their meals at the hospital restaurant.
Various assumptions have been made with respect to the study. First, the study assumes that any serious change in the operations of the emergency department that can disrupt the study will not occur. In this case, I recognize that the management of the hospital can choose to execute certain changes that might interfere with the progress of the study. The study observers will not have any influence over the decisions made by the hospital management under any circumstance. Secondly, we assume that no major event with the ability to influence the need to close down the emergency department will occur. The team carrying out the study would not have any influence over the occurrence of such events. Therefore, in case of such occurrences, the study will definitely be terminated. Consequently, achieving the aims of the study would require a repeat of all the processes that will have been completed by the time of the occurrence of the event. The occurrence would also affect the study in the sense that the resources used will have been wasted.
Another assumption made with regard to this study is that at least some of the recruited triage nurses and the EMS will be available to take part in the study. In other words, there will be no time that all the recruited participants will be unavailable to take part in the study. This assumption takes into consideration the fact that if all the participants are fired or drop out of the study, the study will fail to proceed to conclusion. Indeed, the study will stall. The study also assumes that at least some targeted participants will accept to take part in the study. This assumption is based on the fact that the research team of the study has no influence over a possible decision of the prospective participants to refuse to take part in the study. Therefore, the study can only take place if a reasonable number of the targeted participants agree to take part in the study. Another assumption of the study is that there will be no massive withdrawal of participants from the study. With this regard, I recognize that for a study to be valid and reliable, the number of participants taking part in the study must be reasonable and must meet the scientific standards. Consequently, massive withdrawal of participants is likely to derail the validity and reliability of the study. Therefore, a study in which massive withdrawal of the participants is witnessed ceases to provide findings that can be used to influence key decisions in professional practices.
At this time, the organization’s IRB application is pending. Although, data collection has not occurred, for the purposes the DNP program; I will demonstrate the data analysis from a similar study based on information collected with the IMIST-AMBO protocol.
The study observed 75 handoffs from the pre-hospital staff/EMS to the receiving hospital nurses. Table 1 and Graph 1 (Schmidst, 2014) demonstrated the score assigned from 0-9 based on the categories of the hand off report protocol, IMIST-AMBO tool. Also displayed are the frequencies of IMIST-AMBO categories present during the handoff process. Graph 1 visually exhibits the scores most frequently during the observation; with the most common score being three. Table 2 further breakdown the nine categories and displays not only what information was transferred during the hand of process, but what was not mention or discuss during the procedure.
Graph 1. Handoff Score Frequency
The purpose of this study was to examine the exiting handoff reporting methods and documentation from pre-hospital personnel to ED staff; and identify issues with the current process. The study applied a correlation statistical analysis to examine the relationship from the data identified from the protocol and the documentation in the electronic medical record. The sample was obtained by ambulance patients arriving in the ED during all shifts and days of the week for a time frame of one month. The sample size included seventy-five observed handoffs. From the witnessed hand off reports, the analysis included a percentage distribution to organize the data according to the nine categories of the IMIST-AMBO protocol. The data was divided and compared according to the categories of information transferred through application of the protocol and analyzed for frequency of occurrence. The electronic medical record was then reviewed and analyzed using percentage distributions according to the format used for handoff reporting to validate if the data was documented.
In the study, a handoff score 0-9 was assigned to established the categories of the hand off report as identified by the IMIST-AMBO collection data tool. Based on the scale the average score was 3.29. Table 1 and Graph 1 (Schmidst, 2014) displayed the frequencies of scores for the handoff reports observed. Scores of the handoffs ranged from 1 to 5 with 5 being the highest. The most common score was 3 with 26 of 75 (35%) of the handoffs being scored at this number. The author of the study only utilized the score from category 1 to 5, mostly likely due to minimal responses to category 6-9.
This study demonstrated there is a lack of patient information transfer based on the IMIST-AMBO tool. The average score of 3 verifies the low level handoff communication. There was no consistency in the categories of patient history, medical problem, medication, allergies, and social history. Schmidt (2014) was unable to determine if there were other sources of information, for example family member with patient. Also, an electronic chart audit was conducted, to measure the fulfilment of the nursing documentation; and it was found only 13% was compliant with the handoff report.
The data reflects the lack of pertinent information being transferred and establishes probable risk regarding the patient safety during the handoff process. The literature review showed there is potential for adverse effects to occur due to low quality handoffs. Iedema (2012) suggested handoff should be accurate and effective to allow care to be continuous and prevent the miscommunication of critical information.
The goal of the study was achieved; identify gaps of information exchange, which can potentially harm patients during the hand off process. The results suggest further research in the hand off process, and investigate alternatives to improve practice; for example how can technology enhance the process? The result validates, the recommendation of the development of a standard handoff reporting practice with the IMIST-AMBO protocol. The pre-hospital staff/EMS and receiving nurses will need further instruction on the protocol and stress the importance of compliance of documentation in the medical record.
The findings in this study demonstrate the ineffective communication at its present state and I predict similar findings at Elmhurst Hospital Emergency Department. It supports clinical communication and how handoffs plays an important role in quality and safety of patients in the emergency department. The emphasis should be designed to assist health professionals to improve the patient transitions of care. The recommendation is to regulate and standardize the process. With the use of the IMIST-AMBO protocol, staff will be able to transfer the patient’s information in concise and consistent manner, which creates an environment of safety. Patient safety is of the upmost importance in every aspect of care including handing off information and transferring responsibility. “Health care organizations must develop a “culture of safety” such that their workforce and processes are focused on improving the reliability and safety of care for patientsthis will mean incorporating a variety of well-understood safety principles, such as designing jobs and working conditions for safety; standardizing and simplifying equipment, supplies, and processes; and enabling care providers to avoid reliance on memory (Institute of Medicine, 1999).
Standardization of the handoff process would partly help improve the effectiveness of transition of care in various hospital departments. In order to develop a standard practice for transferring patient care, much emphasize should be put on improving handoff communication between healthcare professionals. In this case, development of an appropriate protocol for handoff communication is crucial. The study demonstrated in the analysis section above utilized the IMIST-AMBO protocol to help detect the problems associated with the current handoff communication practices. However, the protocol has not been endorsed by a nursing body as the standard protocol to guide handoff communication between healthcare professionals. The first step towards solving the problems in the current handoff communication practices should involve attempts to develop a standard protocol that incorporates all the required aspects of the handoff communication more comprehensively than the IMIST-AMBO protocol. This step can be executed by first developing different protocols and then testing them to determine the protocol that most captures the requirements of handoff communication process and is most applicable in healthcare settings. A different protocol for the emergency departments should also be developed. This protocol should be developed in consideration of the fact that emergency departments are characterized by the need for fast transfer of information and immediate interventions.
Standardization of the handoff communication process would be more feasible with the use of a standard protocol. Indeed, the development of a standard protocol is the mainstay of standardization. Standardization would be very helpful in monitoring the transfer of professional responsibility and accountability in various departments. Besides, it would help in setting regulations to help facilitate the process of the transfer of professional responsibility as well as accountability. It would also help assess the efficiency and efficacy of a handoff communication practice. With the standardization of handoff communication process, an environment that encourages patient safety would be created. Scientific evidence should be heavily relied upon in standardizing the handoff communication practices.
Microsystem Change
After presenting the results to the major stakeholder, I anticipated change will occur. Initially, there may be requests for further evaluation including a much larger sample size. If results are consistent, there is an expectation, steps will be taken to ensure an effective clinical handoff process and limit practice variation. Education will be provided to staff on the importance of clinical handoff. EMS and triage nurses will have a better understanding of the roles and responsibilities. Training based on the IMIST-AMBO protocol will occur, creating a new standard of practice and producing new policies. To create a supportive culture which values clinical handoffs, there will be regular monitoring and evaluation of the new process; to protect the new protocol, and maintain the new change. After standards of practice and protocol has been established in the microsystem and other EDs in the healthcare system it is the aim of this student to approach policy makers to place this new standard of care into practice statewide.
The microsystem is also expected to put more efforts towards conducting researches aimed at investigating the correlation between handoff practices and cases of errors in the emergency department. This research will help ascertain whether various handoff practices pose different levels of threat to patient safety especially in the emergency department. In addition, the findings of this study are expected to prompt more efforts from various stakeholders to investigate the various factors that most commonly lead to inefficient and ineffective handoff communication. As a result, the stakeholders are expected to come up with feasible and sustainable solutions for these factors in order to help promote safety of patients. The key decision makers are also expected to commission a similar study in the different emergency departments of various health facilities using different protocols. This should be followed by another study with an aim of investigating the prevalence of errors in the emergency departments. Findings from these studies would the help evaluate the effectiveness of the various protocols developed to be used in handoff communication.
This study is expected to inform key decisions affecting the practice in the emergency department of the facility. In addition, the study findings are expected influence important changes in the care practice processes in the emergency department as well in the entire hospital. Apart from the emergency department, the findings from this study are likely to influence health practices in the other departments of Elmhurst Hospital. Eventually, key decision makers and other stakeholders in the entire healthcare system of the United States might initiate key processes of reviewing the various healthcare policies and practices on the basis of findings of other studies carried out in response to the findings of this study.
Appendix - A
Appendix – B
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On 8 Jan 2015, at 5:49, wrote:
Good Day
My name is and I am currently pursuing a Doctor of Nursing Practice degree at Chamberlain College of Nursing, in Addison, Illinois in the United States. I will be conducting a study, analyzing the initial hand-off communication in the Emergency Department at Elmhurst Hospital, part of the Health and Hospital Corporation in New York. I am requesting permission to utilize your evaluation tool protocol "IMIST-AMBO" documented in the article, " Design and trial of a new ambulance-to emergency department handover protocol: "IMIST-AMBO". Please let me know if there is a fee attach for using the protocol. And please contact me if there are any questions regarding my study. Thank you for your time and consideration.
Appendix – C
Chamberlain College of Nursing
Institutional Review Board (IRB)
3005 Highland Parkway
Downers Grove, IL 60515-5799
Federal Registration: IRB00009799
Federal Wide Assurance: FWA00021986
Dear :
This letter is to inform you that the Chamberlain College of Nursing (CCN) Institutional Review Board (IRB) for the Protection of Human Subjects has received and processed your proposal titled: Assessment of Initial Handoff Communication in the Emergency Department. Your proposal was assigned IRB # 2015-02-02-EXM which should be referenced in future communications.
The IRB has determined that your project is exempt from IRB oversight and continuing review since it meets the criteria indicated below as described in DHHS Regulations for the Protection of Human Subjects (45 CFR 46).
_____ The proposed project does not include human subjects.
_____ The proposed project will not produce findings useful to external audiences or contribute to the knowledge base in a given field (broad definition of “research”).
_____ The proposed project will be conducted in established or commonly accepted educational settings, involving normal education practices. (45.CFR.46.101[b][1])
__X___ The proposed project will involve the use of educational tests, survey procedures, interview procedures or observations of public behavior (unless information obtained is recorded in such a manner that human subjects can be identified directly or through identifiers linked to the subjects; and any disclosure of the human subjects’ responses outside the research could reasonable place the subjects at risk of criminal or civil liability or be damaging to the subjects’ financial standing, employability, or reputation). (45.CFR.46.101.[b][2])
_____ Other exemption criterion (State: _________________________)
Although your study is exempt from IRB oversight, you are expected to follow the conventions of research ethics described in the Belmont Report and relevant professional guidelines. If aspects of your study change such that IRB oversight will become necessary, you must contact the IRB immediately.
If you have any questions, do not hesitate to contact the IRB. Best wishes with your scholarly inquiry!
Marty Spies Patricia Fedorka
Marty Spies, Co-Chair Patricia Fedorka, Co-Chair
Bruce, K., & Suserud, B. (2005). The handover process and triage of ambulance-born patients: the experiences of emergency nurses. British Association of Critical Care Nurses, 10(4), 201-209.
Dawson, S., King, L., & Grantham, H. (2013). Review article: Improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient. Emergency Medicine Australasia, 25(1), 393-405.
Dufault, M., Duquette, C., Ehmann, J., Hehl, R., & Lavin, M. (2010). Translating an evidence-based protocol for nurse to nurse shift handoffs. Worldviews on Evidence-Based Nursing, 7(2), 59-75.
Evans, S. M., Murray, A., Patrick, I., Fitzgerald, M., Smith, S., Andrianopoulos, N., & Cameron, P. (2010). Assessing clinical handover between paramedics and the trauma team. Injury International, 41(1), 460-464.
Iedema, R., Ball, C., Daly, B., & Young, J. (2012). Design and trial of a new ambulance-to-emergency department handover protocol: IMIST-AMBO. BMJ Quality Safety, 21(1), 627-633. from
Jensen, S. M., Lippert, A., & Ostergaard, D. (2013). Handover of patients: a topical review of ambulance crew to emergency department handover. ACTA Anaesthesiol Sandinavica, 53(1), 964-970.
Manser, T., & Foster, S. (2011). Effective handover communication: An overview of research and improvement efforts. Best Practice & Research Clinical Anaesthesiology, 25, 181-191. from
Maughan, B. C., & Lei, L. (2011). ED handoffs:observed practices and communication errors. The American Journal of Emergency Medicine, 29(5), 502-511. from
Owen, C., Hemmings, L., & Brown, T. (2009). Lost in translation: Maximizing handover effectiveness between paramedics and receiving staff in the emergency department. Emergency Medicine Australasia, 21(1), 102-107. from
Project Detail - Hand-off Communications. (2013). Retrieved, from
Schmidst, K. (2014). Handoff communication in the emergency department (Master’s thesis). Retrieved from
Ye, K., Taylor, D., Knott, J., & Dent, A. (2007). Handover in the emergency department: deficiencies and adverse effects. Emergency Medicine Austrialasia, 19(1), 433-441. from
Young, G., Dent, A. W., & Weiland, T. J. (2008). Handover from paramedics: Observations and emergency department clinician perceptions. Emergency Medicine Australasia, 20(1), 149-155.

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