Ineffective Communications in the Pre-Hospital Setting

In responding to a request for client transportation, effective communication can be challenging due to factors such as balancing time sensitive emergencies, multiple providers and timely handovers, technology failures, variation in communication expectations, and practices across involved centres, hospitals, specialty teams, and practitioners. Ineffective or limited communication among paramedics, hospital-based transport teams, medical escorts, most responsible practitioners (MRPs), other hospital staff, and / or dispatch staff may result in a negative outcome for the client, such as the wrong treatment or delays in essential assessments, tests, and treatments.

Expected Outcomes

Adopt standardized and structured team communication and coding system for classifying and prioritizing client transport.

Implement formal strategies to develop and maintain a work environment which supports and expects:
o        Early response to suspected and actual clinical deterioration;
o        Assertive and respectful questioning and challenging of care decisions (standardized and formalized chain of command protocol);
o        Zero tolerance of intra- and inter-disciplinary bullying and intimidation.

Definitions and Acronyms

• Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
• EMS – emergency medical services also known as ambulance services or paramedic services
• MRP – most responsible practitioner, often a midwife, nurse practitioner or physician
• Medical directives - an indirect order that gives authorization to a care provider or group of care providers (e.g., ED nurses) to implement the order (e.g., ED chest pain for adults) with a predefined patient population (e.g. ED patients presenting with symptoms suggestive of cardiac ischemia or cardiovascular symptoms such as discomfort jaw to umbilicus, upper limb discomfort without known injury, chest trauma…)
• RT – respiratory therapist
• Situational awareness – deliberate and active scanning and assessing of the situation to maintain a holistic understanding of the environment in which the team is functioning

Common Claim Themes and Contributing Factors

Communication Hot Spots 

• Failure to use pre-hospital EMS decision support tools, algorithms, and protocols where available. 
• Lack of familiarity and / or compliance with regional or local pre-hospital EMS protocols and medical directives.
• Lack of familiarity with providers (e.g., midwives) scope of practice impacting effective communication and decision making.
• Technology issues prior to and during transport resulting in incomplete and / or misinterpreted instructions and delayed care.
• Failure to communicate and document the rationale for not applying or following EMS / transport protocols, medical directives, etc. 
• Failure to recommend and / or request air transport (where indicated) or an alternative EMS provider due to communication breakdowns between the sending community / facility MRP and / or team, ambulance dispatch and / or consulting / transport physician / practitioner.
• Role confusion, in particular:
  • Sending community / facility MRP;
  • Land and aircraft paramedic / EMS teams;
  • Consulting and / or transport physicians, midwives or practitioners overseeing the prioritization, mode of transport, and care decisions following a request for transport;
  • Ambulance dispatch and coordinators.
• Inconsistent and delayed communications from the EMS team to the sending community / facility MRP or team regarding:
  • Expected arrival timeline of the transport team;
  • Transport team staffing issues (e.g., duty hours, absence of an advanced care paramedic) and the need for medical escorts and specialized equipment;
  • Downgrades to the level of care / urgency and mode of transport.
• Ineffective communications between EMS and clients due to language barriers and cultural differences.
• Failure to act upon and / or dismissal of recommendations and concerns regarding the mode of transport expressed by the:
  • EMS team;
  • Sending community / facility MRP or team;
• Inappropriate details provided by sending facility regarding level of care required for client and equipment needs.

Mitigation Strategies

Communication

• Adopt a standardized and structured form of communication to reduce communication failures (e.g., SBAR and ATMIST AMBO) (BC Emergency Health Services, 2023) (Bain, et al., 2022).
• Implement a formal IT system downtime protocol / standardized operating procedures for ambulance dispatch and coordinating agencies that address (but are not limited to) the specific steps / actions to be taken if there is a technology failure including anticipated and unanticipated (e.g., third party downtimes, cyber threat) system downtimes and outages (Massachusetts General Hospital Centre for Disaster Medicine, 2018).  
• Adopt a standardized coding system for classifying and prioritizing client transport for both on scene response and interfacility transfers; where possible, align coding system and prioritization practices with municipal and contracted ambulance dispatch and service providers; include both ground vehicle and aircraft service providers (Ministry of Health Ministry of Long-Term Care, n.d.) (Alberta Health Services, 2020) (Alberta Health Services Emergency Medical Services, 2017).
• Implement formal multifaceted and targeted strategies to support and enhance the reliability of ambulance dispatch team communication with the sending facility regarding:
  • Anticipated, foreseeable, and known delays in transport team arrival;
  • EMS staffing issues (e.g., only one RT is available and an advance care nurse or RT medical escort is required).
• Adopt a standardized evidence-informed / best practice retention period for all dispatch audio recordings (Alberta Health Services, 2022). 
• Adopt a standardized and formalized communication backup / contingency plan for the rapid response for when:
  • The most responsible transport physician / practitioner or sending MRP does not respond or is unable to respond within an appropriate timeframe;
  • If there is a technology failure (e.g., anticipated and unanticipated system downtimes and outages of functions; patch failures).
• Implement strategies to ensure the communication backup / contingency plan is updated based on human health resource changes and challenges.

Health Equity

• Implement strategies to support health equity in the pre-hospital care settings (e.g., strategies to improve access to language interpretive services in the pre-hospital setting, to reduce care / transfer / offload disruptions when providing services to uninsured persons) (Sadaka, 2022) (Noack, Kleinert, & Muller, 2020).

Safety Culture

• Implement formal strategies to develop and maintain a work environment which supports and expects:
  • Early response to suspected and actual clinical deterioration, including seeking assistance from peers and other resources (where available);
  • Assertive and respectful questioning and challenging of care decisions (in order to obtain clarity and / or to advance client safety concerns);
  • Zero tolerance of intra- and inter-disciplinary bullying and intimidation (CSA Group, 2018).
• Adopt a standardized and formalized chain of command (‘escalation’) protocol for the rapid escalation of unresolved care disagreements related to concerns about questionable client conditions, orders, or care delivery (Canadian Medical Protective Association, 2021) (Canadian Patient Safety Institute, 2020) (Alberta Health Services Emergency Medical Services, 2017). 

Team Training and Education

• Implement formal strategies to support and enhance the interdisciplinary EMS transport team’s clinical knowledge, skills (technical and non-technical) and practical experience surrounding (but not limited to):
  • Diagnosis errors (e.g., considering differential diagnosis; obtaining enough information to formulate a diagnosis; revisiting the diagnosis if symptoms persist; avoiding workarounds and inappropriate deviations from standard practice; awareness of cognitive biases);
  • Effective communication and active listening skills;
  • Initial and ongoing medical knowledge and medical terminology for emergency medical dispatchers;
  • Training of physicians and practitioners overseeing or directing transport decisions in all modes of ambulance transport including ground vehicles and rotary and fixed wing aircraft where utilized.
• Ensure the scheduled interprofessional and cross-department / sites team training and education strategies consider or involve: 
  • Opportunities for interdisciplinary skill drills and simulations; 
  • Team and practitioner situational awareness (helicopter view’) and human factors;
  • Program areas, sites, and practitioners with limited practical experience or expertise with medical emergencies and transport medicine;  
  • Unregulated care providers, travel, locums, agency, contracted care providers in addition to regulated health professionals.

Documentation

Strategies for EMS Educators and Leadership

• Implement formal strategies to ensure complete and timely documentation of EMS-related care and decision making by emergency medical dispatch staff, paramedics, and designated physicians and practitioners overseeing or directing transport decisions on behalf of the hospital, health region, or EMS agency.

Additional Considerations

Examples of areas of improvement related to pre-hospital EMS related documentation:

• Client assessments and monitoring;
• Client risk factors (mechanism of injury, cardiac, co-morbidity, age, victim of violence, parental concerns, etc.);
• Client refusals of examinations, treatments, and transfers;
• Medical directives and / or protocols implemented (name of initiator, directive name and / or number, and date and time initiated, etc.);
• Substantive communication between ambulance dispatch, paramedic / EMS team, and the sending MRP or facility;
• Rationale for interventions not performed;
• Completing forms and checklists in full;
• Language and terms used to communicate and document the status to the most responsible transport physician or practitioner (e.g., avoid use vague or ambiguous language to describe findings). 

Monitoring and Measurement    

• Adopt a standardized, interdisciplinary, collaborative and evidence-based protocol for conducting quality of care reviews involving pre-hospital EMS resulting in client harm or death (Machen, 2023); incorporate system thinking and human factors concepts into the review process; and consider partnering with facilities (e.g., health regions, hospitals, midwifery led birth centres) and community based partners in reviews.
• Adopt standardized current best practice quality indicators for the pre-hospital EMS settings (land and air) (Edwards, FitzGerald, Franklin, & Edwards, 2020) (Basnett, 2022) (National EMS Quality Alliance, 2021) (Health Quality Council of Alberta, n.d.) (Ministry of Health Ministry of Long-Term Care, n.d.) (Bigham, et al., n.d.).
• Incorporate learning from local, provincial, and national pre-hospital EMS safety reviews and data into local protocols as well as staff education and training.  

References

• Alberta Health Services. (2020, 2). AHS EMS Dispatch. Retrieved from Alberta Health Services: https://www.albertamfr.ca/data/documents/Response_Plan_Codes.pdf?A78DC3EF-CEFE-417E-A2F6C719298D310D
• Alberta Health Services. (2022, 3). Records Retention Schedule (1133-01_. Retrieved from Alberta Health Services: https://www.albertahealthservices.ca/assets/info/hp/him/if-hp-him-records-retention-schedule.pdf
• Alberta Health Services Emergency Medical Services. (2017, 6). EMS MCI Response Plance. Retrieved from Alberta Health Services: https://www.albertamfr.ca/data/documents/MCI_Response_Plan_(final).pdf
• Bain, T., Al-Khateeb, S., Bhuiya, A., DeMaio , P., Soueida, S., Jarvis, T., . . . Wilson, M. (2022, 8). Rapid synthesis: Identifying approaches to optimal management of ambulance-to-hospital offload processes. Retrieved from https://www.mcmasterforum.org/docs/default-source/product-documents/rapid-responses/identifying-approaches-for-optimal-management-of-ambulance-to-hospital-offload-processes.pdf?sfvrsn=9d809fdb_7
• Basnett, E. (2022). California EMS System Core Quality Measures Report Calendar Year 2021. Retrieved from https://emsa.ca.gov/wp-content/uploads/sites/71/2022/11/CQM-Report-Final-SYS-100-12-2021-Data_11.29.2022.pdf
• BC Emergency Health Services. (2023, 3). A03:Clinical Handover and Communication. Retrieved from https://handbook.bcehs.ca/clinical-practice-guidelines/a-general/a03-clinical-handover-communication/
• Bigham, B., Morrison, L., Maher, J., Brooks, S., Bull, E., Morrison, M., . . . Shojania, K. (n.d.). Patient Safety in Emergency Medical Services Advancing and Aligning the Culture of Patient Safety in EMS. Retrieved from https://www.patientsafetyinstitute.ca/en/toolsresources/research/commissionedresearch/patientsafetyinems/documents/patient%20safety%20in%20ems%20full%20report.pdf
• Canadian Medical Protective Association. (2021). Resolving conflict between healthcare providers. Retrieved from https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2021/resolving-conflict-between-healthcare-providers
• Canadian Patient Safety Institute. (2020). The Safety Competencies: Enhancing Patient Safety Across the Health Professions. 2nd Edition. Edmonton, AL.
• CSA Group. (2018). Z1003.1-18 Psychological health and safety in the paramedica service organization. Toronto ON: CSA Group. Retrieved from https://www.apbc.ca/wp-content/uploads/2022/09/CSA-Z1003.18-Paramedic-Psych.pdf
• Edwards, K., FitzGerald, G., Franklin, R., & Edwards, M. (2020). ir ambulance outcome measures using Institutes of Medicine and Donabedian quality frameworks: protocol for a systematic scoping review. Syst Rev, 9(72). doi:doi.org/10.1186/s13643-020-01316-
• Health Quality Council of Alberta. (n.d.). New Study: EMS Key Performance Indicators. Retrieved from https://hqca.ca/feature-story/new-study-ems-key-performance-indicators/
• Machen, S. (2023, 5). Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Quality, 12(2), e002020.
• Massachusetts General Hospital Centre for Disaster Medicine. (2018, 7). Hospital Preparedness for Unplanned Information Technology Downtime Event. Retrieved from Massachusetts General Hospital: https://www.massgeneral.org/assets/mgh/pdf/emergency-medicine/downtime-toolkit.pdf
• Ministry of Health Ministry of Long-Term Care. (n.d.). Land Ambulance Key Performance Indicators. Retrieved from https://www.health.gov.on.ca/en/pro/programs/emergency_health/land/default.aspx
• Ministry of Health Ministry of Long-Term Care. (n.d.). Emergency Health Services Ambulance Call Report (ACR) Codes. Retrieved from Ministry of Health Ministry of Long-Term Care: https://www.health.gov.on.ca/en/pro/programs/emergency_health/edu/acr_codes.aspx#1
• National EMS Quality Alliance. (2021). NEMSQA Measures. Retrieved from National EMS Quality Alliance: https://www.nemsqa.org/measures
• Noack, E., Kleinert, E., & Muller, F. (2020). Overcoming language barriers in paramedic care: a study protocol of the interventional trial ‘DICTUM rescue’ evaluating an app designed to improve communication between paramedics and foreign-language patients. BMC Health Services Research, 20(223). doi:doi.org/10.1186/s12913-020-05098-5
• Sadaka, N. (2022). Language Barriers in an Out-of-Hospital Setting. Journal of Emergency Medical Services. Retrieved from https://www.jems.com/patient-care/language-barriers-in-an-out-of-hospital-setting/