A review of enhanced paramedic roles during and after hospital handover of stroke, myocardial infarction and trauma patients

Abstract

BackgroundAmbulance paramedics play a critical role expediting patient access to emergency treatments. Standardised handover communication frameworks have led to improvements in accuracy and speed of information transfer but their impact upon time-critical scenarios is unclear. Patient outcomes might be improved by paramedics staying for a limited time after handover to assist with shared patient care. We aimed to categorize and synthesise data from studies describing development/extension of the ambulance-based paramedic role during and after handover for time-critical conditions (trauma, stroke and myocardial infarction).MethodsWe conducted an electronic search of published literature (Jan 1990 to Sep 2016) by applying a structured strategy to eight bibliographic databases. Two reviewers independently assessed eligible studies of paramedics, emergency medical (or ambulance) technicians that reported on the development, evaluation or implementation of (i) generic or specific structured handovers applied to trauma, stroke or myocardial infarction (MI) patients; or (ii) paramedic-initiated care processes at handover or post-handover clinical activity directly related to patient care in secondary care for trauma, stroke and MI. Eligible studies had to report changes in health outcomes.ResultsWe did not identify any studies that evaluated the health impact of an emergency ambulance paramedic intervention following arrival at hospital. A narrative review was undertaken of 36 studies shortlisted at the full text stage which reported data relevant to time-critical clinical scenarios on structured handover tools/protocols; protocols/enhanced paramedic skills to improve handover; or protocols/enhanced paramedic skills leading to a change in in-hospital transfer location. These studies reported that (i) enhanced paramedic skills (diagnosis, clinical decision making and administration of treatment) might supplement handover information; (ii) structured handover tools and feedback on handover performance can impact positively on paramedic behaviour during clinical communication; and (iii) additional roles of paramedics after arrival at hospital was limited to ‘direct transportation’ of patients to imaging/specialist care facilities.ConclusionsThere is insufficient published evidence to make a recommendation regarding condition-specific handovers or extending the ambulance paramedic role across the secondary/tertiary care threshold to improve health outcomes. However, previous studies have reported non-clinical outcomes which suggest that structured handovers and enhanced paramedic actions after hospital arrival might be beneficial for time-critical conditions and further investigation is required.

Paramedic experiences of using an enhanced stroke assessment during a cluster randomised trial: a qualitative thematic analysis

“…[19][20][21] There have been no previous descriptions of a stroke-specific handover. 22 Accounts of the handover process highlighted barriers the paramedics experienced when attempting to adhere to a prehospital research protocol, especially due to clinical time and resource pressures during emergency stroke care. This was previously reported in the UK during the RIGHT pilot trial of Glyceryl Trinitrate patches 23 and by US paramedics who had assisted with the FAST-MAG trial of intravenous magnesium infusion.…”

“…A systematic review of enhanced paramedic roles during and after hospital handover of conditions amenable to time critical therapies (stroke, myocardial infarction and trauma) found no previous studies describing any similar extension of clinical involvement for comparison. 22 Although interviewees found personal value from staying with the patient longer, it does not seem likely that there was a significant additional contribution to patient care. This is consistent with previous research examining cross-boundary pathways in general, which highlighted the need to consider all aspects of implementation if integration between professions is to succeed.…”

Strategies to measure and improve emergency department performance: a scoping review

“…Seven reviews examined interventions relating to patient handover processes and transitions in care. Patient handover processes and transitions in care interventions include handover tools [27][28][29][30], bedside registration [19,31], discharge planning [31], discharge communication [32], process protocols and guidelines [27,29,30], handover training [29], dedicated offload nurse for triaging and assessing EMS patients [30], nurse discharge coordinators [33]. A description of the characteristics for each Graphical presentation for ROBIS results across all included reviews.…”

“…[28]. For example, Identification, Situation, Background, Assessment, Requirements and Requests (ISBAR) is a tool for face-to-face beside handover [27][28][29][30]. Other tools include Situation, Background, Assessment, Responsibilities and Risks, Discussion and Disposition, Read-back and Record (SBAR-DR) model for verbal handoff, Mechanism of Injury/Illness, Injuries, Signs, observations and monitoring, and Treatment given (MIST; DeMIST includes Demographic information to the handover), hospital developed handover tools, as well as written handover, handover added to patients paper chart, and an eSignout step added to the ED dashboard [27][28][29][30].…”

“…Closely linked with handover tools, process protocols and guidelines outline procedures and rules clarifying the transfer of responsibility, as well as a structure for handover [27,29,30]. Handover training lasting 3 h, covered five rules of communication, case scenario simulation and a handover protocol [29] Discharge Clinical Roles…”